Paul Barbour & Associates | Independent Insurance Broker in Burlington, Ontario

Section 1: Personal Information

Title

First Name *

Middle Name

Last Name *

Social Insurance Number

Date of Birth *

Gender *

City of Birth

Country of Birth

Residence Address *

City *

Province *

Postal Code *

Years at Address

Previous Address (if less than 2 years at current)

Home Phone

Business Phone

Email Address *

Marital Status

Canadian Citizen?

Yes No

If not Canadian, citizenship:

Language Preference

English French

Section 2: Owner/Beneficiary Information

Policy Owner (if different from insured)

Relationship to Insured

Owner Date of Birth

Primary Beneficiary *

Relationship to Insured *

Beneficiary Date of Birth

Contingent Beneficiary

Section 3: Employment Information

Employer Name

Years with Employer

Employer Address

Occupation/Job Title *

Specific Duties

Self-Employed?

Yes No

If self-employed, describe your business:

Section 4: Financial Information

Annual Earned Income *

Annual Unearned Income (investments, etc.)

Approximate Net Worth

Have you ever declared bankruptcy?

Yes No

If yes, provide details:

Section 5: Existing Insurance & Lifestyle

Existing Life Insurance (Company, Face Amount, Year Issued)

Will any existing insurance be replaced?

Yes No

Have you ever been declined, postponed, or rated for life or health insurance?

Yes No

If yes, provide details:

Do you participate in hazardous sports or activities? (skydiving, scuba diving, racing, etc.)

Yes No

If yes, describe:

Do you have a valid driver's license?

Yes No

Any driving violations in last 5 years?

Do you use tobacco or nicotine products?

Never Currently use Quit within 12 months Quit over 12 months ago

If current or former user, type and frequency:

Do you have existing disability income insurance?

Yes No

If yes, monthly benefit amount:

Section 6: Health Information

Height *

Weight (lbs) *

Name of Personal Physician

Physician Address

Physician Phone

Date of Last Medical Exam

Current or past medical conditions, surgeries, or hospitalizations:

Current medications:

Family History (parents and siblings):

Father's Health / Age at Death & Cause

Mother's Health / Age at Death & Cause

Siblings' Health History

Family history of heart disease, cancer, diabetes, or other hereditary conditions?

Yes No

If yes, provide details:

Section 7: Coverage Requested

Face Amount Requested *

Type of Coverage

Additional Information or Special Requests

Medical Questionnaire

Section 1: Personal Information

Section 2: Owner/Beneficiary Information

Section 3: Employment Information

Section 4: Financial Information

Section 5: Existing Insurance & Lifestyle

Section 6: Health Information

Section 7: Coverage Requested