CRITICAL ILLNESS QUOTE

FOR EXISTING CLIENTS ONLY

Fields with an asterisk * are required to complete the quote

General Information

*First Name:

*Email Address:

*Birth Date:

*Weight:

pounds

When did you last use any type of tobacco products?

*Last Name:

*Province:

*Height:

feet

inches

*Gender :

Male Female

*Tel:

*Fax:

The following information can help us provide you with the most accurate quote.

Is your Blood Pressure above 140/85?

3 or more medications 2 medications 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

CRITICAL ILLNESS QUOTE

FOR EXISTING CLIENTS ONLY

Have you been treated or taken medication for any of the following conditions within the past 10 years:

The following information can help us provide you with the most accurate quote.

Is your Blood Pressure above 140/85?

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?

Insurance Needs

Select the amount of insurance needed for this quote.

Payment Mode:

Get a Worry Free
travel insurance quote today!

Get Travel and Insurance News

CRITICAL ILLNESS QUOTE

FOR EXISTING CLIENTS ONLY

Have you been treated or taken medication for any of the following conditions within the past 10 years:

The following information can help us provide you with the most accurate quote.

Is your Blood Pressure above 140/85?

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?

Insurance Needs

Select the amount of insurance needed for this quote.

Payment Mode:

Get a Worry Free travel insurance quote today!

Get Travel and Insurance News

Get a Worry Free
travel insurance quote today!