Critical Illness Quote

Fields with an asterisk * are required to complete the quote

General Information
*First Name:		*Last Name:
*Email Address:		*Province:
*Birth Date:	(MM/DD/YYYY)	*Height:	feet inches
*Weight:	pounds	*Gender:	Male Female
When did you last use any type of tobacco products?		Tel: Fax:

Have you been treated or taken medication for any of the following conditions within the past 10 years:
Alcoholism	Arthritis:
Asthma	Blood Disorder
Blood Pressure (high)	Cancer
Cholesterol	Depression
Disorder of Kidneys, Bladder or Prostate	Diabetes
Drug Abuse	Heart Disease
Disorder of Intestines	Thyroid
Other conditions:

The following information can help us provide you with the most accurate quote.
Is your Blood Pressure above 140/85?	Yes No Don't know
What is your Cholesterol Count?
Have you been a pilot or airline crew member in the past 3 years?
Have you had more than 3 moving traffic violations in the past 3 years?
Have you ever been convicted of a DUI?
Before the age of 60, has anyone in your immediate family (siblings and parents) been diagnosed with cancer, diabetes, or heart or kidney disease?	No Yes

Insurance Needs

Select the amount of insurance needed for this quote.

Payment Mode:
(Note that insurance carriers will typically charge a nominal surcharge for the Quarterly or Semi-annual Payment Modes)
Monthly Quarterly Semi-Annual Annual

First Rate Insurance Inc.
All right Reserved, © 2006; www.firstrateinsurance.com