Medical Questionnaire
Fields marked with * are required
Section 1: Personal Information
Title
First Name *
Middle Name
Last Name *
SIN
Date of Birth *
Gender *
City of Birth
Country of Birth
Residence Address *
City *
Province *
Postal Code *
Yrs 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, citizenship:
Language: 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 DOB
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
Approximate Net Worth
Declared bankruptcy?
Yes No
If yes, details:
Section 5: Existing Insurance & Lifestyle
Existing Life Insurance (Company, Face Amount, Year)
Will any existing insurance be replaced?
Yes No
Ever declined, postponed, or rated for insurance?
Yes No
If yes, details:
Participate in hazardous sports/activities?
Yes No
If yes, describe:
Valid driver's license?
Yes No
Driving violations in last 5 years?
Tobacco/nicotine use: Never Current Quit < 12 mo. Quit > 12 mo.
If user, type & frequency:
Existing disability income insurance?
Yes No
If yes, monthly benefit: $
Section 6: Health Information
Height (ft) *
Height (in)
Weight (lbs) *
Name of Personal Physician
Physician Address
Physician Phone
Date of Last Medical Exam
Current/past conditions, surgeries, hospitalizations:
Current medications:
Family History (parents & 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 hereditary conditions?
Yes No
If yes, details:
Section 7: Coverage Requested
Face Amount Requested *
Type of Coverage
Additional Information or Special Requests
Privacy Notice: Your information will be sent securely to Paul Barbour and kept confidential. It will only be used for processing your insurance application.
Signature
Date
Paul Barbour & Associates Financial Services Inc. | 905-639-3501 | paul@barbourfinancial.com