Sex
Male
Female
Smoker?
Yes
No
Date of Birth
-
Month
-
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Eligibility
I confirm that I have not received any diagnosis of cognitive impairment and confirm being able to perform regular daily living activities such as bathing, dressing, toileting, maintaining continence, moving and eating by myself?
*
Yes
No
In the last 12 months, did you work at least 28 weeks and at least 21 hours per week?
Yes
No
I confirm that I have not received any diagnosis of cognitive impairment and confirm being able to perform regular daily living activities such as bathing, dressing, toileting, maintaining continence, moving and eating by myself?
Yes
No
In the last 2 years, were you absent from work for more than 15 consecutive days due to Illness or did you receive disability or critical Illness benefits under a private, group or public insurance plan?
Yes
No
In the last 2 years, did you receive treatment or were you advised to seek treatment regarding the use of drugs or alcohol?
Yes
No
In the last 6 months, did you have any physical or mental symptoms or discomfort for which you have not yet consulted a health professional?
Yes
No
Sorry, you are not eligible at this time
We regret to inform you that you are not eligible for our insurance without medical exam. However, we recommend that you get in touch with your Broker (Financial Security Advisor) to identify an alternative solution.
Name
*
First Name
Last Name
Phone Number
-
Area Code
Phone Number
Email
*
example@example.com
Submit
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