Paul Barbour & Associates - Financial Service.

Please note this page may take few minutes to download.

Kindly ask you to Print an fill out the following pages and Fax them to (905) 639-3453

Home

SECTION 1

Dr.

Mr.

Mrs.

Ms.

Miss.

Male

Female

Smoker Nonsmoker*

*A nonsmoker has not smoked or used any tobacco product in the past 12 months; a nonsmoker by this definition qualifies for nonsmoker rates.

First Name:	Middle Name:	Last Name:
Former Name (if applicable):	Social Insurance Number (S.I.N):	Birthdate:
Age:	Birthplace (Prov/Country):

RESIDENCE ADDRESS

Street:	Apt.
City:	Province:	Postal Code:

PREVIOUS ADDRESS

Complete if Proposed Insured has been at current address for less than 2 years.

Street:	Apt.
City:	Province:	Postal Code:

GENERAL INFORMATION

	YES	NO
1. Are you a Canadian Citizen?
2. Can you understand, read and speak English fluently?
3. Can you understand, read and speak French fluently?

4. I would prefer my policy in:	English	French
5. How long have you worked in Canada?
6. Customer Interview:	Day	Evening
Specific Time:
7. Mailing address:	Business	Residence

SECTION 2

OWNER

To be completed if the Owner is not the Proposed Insured. If the sOwner's address is different from the Employer, include the address in Agent/Broker Remarks.

First Name:	Middle Name:	Last Name:
Business Name (if applicable):	Relationship to Proposed Insured:

	Proposed Insured	Owner
Benefits payable to:
Premium will be paid by:
Send premium notice to:

BENEFICIARY

If the Beneficiary is other than Estate, complete the following for any amount payable due to Insured's death. If under age 18, a Trustee should be elected.

First Name:	Middle Name:	Last Name:
Relationship to Proposed Insured:
In Quebec, if primary beneficiary is owner's spouse, is this designation: Revocable? Irrevocable?

SECTION 3

EMPLOYER/BUSINESS ADDRESS

Employer/Business Name:	Street:	Suite:
City:	Province:	Postal Code:
Business Telephone No.

How long have you been with this employer/business?

Years:

Months:

GENERAL

1. Number of hours currently worked:

Weekly:

Daily:

	YES	NO
2. Do you work From home?
3. Is employment year round? If "No", state months worked: _______________________________________________________ _______________________________________________________
4. Any part-time or seasonal employment? If "Yes", describe exact duties and number of hours worked: _______________________________________________________ _______________________________________________________ _______________________________________________________
5. Do you anticipate changing job titles, occupation or employer within the next 12 months? If "Yes", give details: _______________________________________________________ _______________________________________________________ _______________________________________________________
6. Do you intend to travel, work, or reside outside of Canada within the next 12 months, other than for vacation? If "Yes" give details: _______________________________________________________ _______________________________________________________ _______________________________________________________
7. Have you been unemployed in the past 3 years? If "Yes" give details: _______________________________________________________ _______________________________________________________ _______________________________________________________

SELF-EMPLOYED

	YES	NO
Are you self-employed? If "Yes", answer the following.

1. Organization of business:
Sole Proprietorship	Partnership	Corporation

2. Percentage ownership:
3. Number of partners/principals:
4. Number of full-time employees (excluding owners):
5. Number of part-time employees:
6. Date self-employed on a full-time basis (M/Y):

DESCRIPTION OF OCCUPATION

Job Title:
Professional Degree or Designation (Area of specialty if any):
Nature of Business:

Job Duties		% of Time	Description of Duties
1. Administrative/Office
2. Manual/Physical
3. Sales
4. Travel
5. Other:
6. Supervision/Management			COMPLETE THE CHART BELOW

Supervision/Management by location:		% of Time	No. of Employees	Job Duties of Employees Supervised/Managed
	Office
	Shop/Plant/Field Office
	Project/Job Site

SECTION 4

	Yes	No
Have you ever filed for personal bankruptcy?			If "Yes" give date of discharge (D/M/Y):
Have you ever filed for business bankruptcy?			If "Yes" give date of discharge (D/M/Y):

Full Financial documentation is required for the most recent 2 years for all coverage amounts.
The TOTAL EARNED and TOTAL UNEARNED amounts must be completed and the Net Worth question
must be answered on this application.

Completing the remaining information on this page will assist you in determining insurable earnings; however, these details are optional.

EARNED INCOME

Current Year To Date		Prior Year	2 Years Prior
	No. of Months: ____	19____	19____

1. EMPLOYED
EMPLOYEE	COMMISSION EMPLOYEE

Annual Earned Income (Salary, fees, bonuses, commissions):	$	$	$
Lines 101 and 104 of T1 General Income Tax Return less Line 229 for Commission Employee

2. SELF-EMPLOYED
SOLE PROPRIETOR	PARTNER	SHAREHOLDER

For the business:
Fiscal year end of business (D/M):___________
Gross Annual Earned Income:	a)	$	$
Business Expenses:	b)	$	$
Net Annual Profit (or Loss) before taxes: Subtract b) Business Expenses from a) Gross Annual Earned Income	c)	$	$

To determine Proposed Insured's Annual Earned Income:
Annual Earned Income (Salary, fees, bonuses, commissions): Lines 10, 104, 135, 137, 139, 141 and 143 of T1 General Income Tax Return.	d)	$	$
Percentage of Net Annual Profit (or Loss) of Business: ______% Cannot exceed % of ownership; submit Financial Statements	e)	$	$
Total Self-Employed Earned Income: Add d) Annual Earned Income to e) Net Annual Profit (based on percentage) or subtract this amount if business is operating at a loss	f)	$	$
	f)	$	$

3. OTHER SOURCES OF EARNED INCOME
Contributions to pension or profit sharing by employer:	a)	$	$
Other:________________________________ For "Other", explain and submit appropriate income tax documentation	b)	$	$

4. TOTAL EARNED INCOME (Must be completed on all applications.)

UNEARNED INCOME

	Prior Year	2 Years Prior		Prior Year	2 Years Prior
	19___	19___		19___	19___
Dividends:	$	$	Net Rental Income:	$	$
Interest:	$	$	WCB/UIC Received:	$	$
Pension:	$	$	Other:	$	$
Capital Gains:	$	$	For "Other", explain and submit appropriate income tax documentation
TOTAL UNEARNED INCOME (Must be completed on all applications.)				$	$

NET WORTH

All applicants: Does your net worth exceed $4,000,000?	Yes	No
If "Yes", complete below and attach a completed Financial Underwriting Questionnaire.

Assets:	$	$		Liabilities:	$	$
TOTAL NET WORTH Assets minus Liabilities :					$	$

SECTION 5

YES

1. Have you ever had any life or disability insurance declined, postponed, rated, cancelled, rescinded, or modified in any way?

If "Yes", give details:
__________________________________________________________________________
__________________________________________________________________________

2. As a result of a disability, have you ever applied for, received or been refused benefits, settlements, or pension (including Workers' Compensation or government benefits)?

If "Yes", give details:
__________________________________________________________________________
__________________________________________________________________________

3. Have you, within the past 2 years, engaged in motorcycle riding, ATV use, scuba diving deeper than 50 ft., bungee jumping, parachuting, karate, judo, hang-gliding, motor vehicle or motorboat racing, rodeo activities, skiing, mountain climbing, or any other sport or avocations:

If "Yes", specify which sport or avocations:

4. Have you ever piloted an airplane, jet, ultralight or glider, or served as a crew member, or have any intention of doing so within the next 6 months?

5. Have you ever had your driver's license suspended, been convicted of, or have charges pending for any moving traffic violation?

If "Yes", License no.: ______________________
Province: ________________________

6. Have you ever suffered an injury as a result of an automobile accident?

If "Yes" give details:
__________________________________________________________________________
__________________________________________________________________________

7. Have you ever been convicted of, or have charges pending for any criminal offense including drinking/driving offenses?

If "Yes" give details:
__________________________________________________________________________
__________________________________________________________________________

8. Have you ever faced disciplinary action from your professional licensing body, or had your professional license suspended or restricts?

If "Yes", give details:
__________________________________________________________________________
__________________________________________________________________________

9. Have you ever used any of the following:

	Yes	No		Yes	No
Cigarettes			Cigars
Cigarillos			Pipe
Chewing Tobacco			Nicotine Gum
Marijuana			Transdermal
Other			Nicotine Patch

If "Yes", How often and how long have you used each of the above
(i.e. no. of packages per day for specified no. of yrs.)?
__________________________________________________________________________
__________________________________________________________________________

10. If you no longer use any of the above products, please indicate the date (M/Y) and the reason stopped:

___/___ _____________________________________________________________________

___/___ _____________________________________________________________________

	YES	NO
1. Are you covered by: Unemployment?, Workers' Compensation?
2. Are you currently covered by Group LTD, STD or any other type of disability coverage? If "Yes", complete chart below.
3. If there is no Group LTD or STD in force at present, will you be eligible for Group disability insurance within the next 12 months?
4. Except as noted above, do you plan to apply for any type of disability insurance within the next 12 months?

Company Name	Issue Date (M/Y)	Type (code)	Monthly Benefit Amount	% Salary Covered	Elim. Period (Days)	Benefit Period	Benefit Taxable? (Yes/No)	Coverage Status
Company Name	Issue Date (M/Y)	Type (code)	Monthly Benefit Amount	% Salary Covered	Elim. Period (Days)	Benefit Period	Benefit Taxable? (Yes/No)	(Code)	(M/Y)
	/		$						/
	/		$						/
	/		$						/

It is understood that if this application is accepted and a policy is issued and put into effect, and the above change or replacement is not proceeded with, benefits will not be paid under this policy.

SECTION 6

FAMILY HISTORY

	Age if Living	Age at Death	Cause of Death
Father
Mother
Brother(s)

Sister(s)

	YES	NO
Have your biological parents, or siblings ever had diabetes, high blood pressure, stroke, genetic or hereditary disorders, heart disease, neurological or psychiatric illness, alcohol or substance abuse? If "Yes", please explain: ______________________________________________________________ ______________________________________________________________ ______________________________________________________________

HEIGHT AND WEIGHT

Height: ________ft.	________in.	or ________cm.
Weight: ________lb.		or ________kgs.

	YES	NO
Any weight gain or loss within the past year? If "Yes", provide amount and reason for change: ______________________________________________________________ ______________________________________________________________ ______________________________________________________________

Have you ever had, been tested, treated, counseled, or had any known indication of, or been told you had:

	YES	NO
1. Positive HIV (i.e. the AIDS test), Acquired Immune Deficiency Syndrome (AIDS), any other Immune Deficiency Disorder?
2. Enlarged lymph nodes (glands), chronic diarrhea, weight loss, unusual skin lesions, unexplained infections or fevers?
3. High blood pressure, chest pain or discomfort, shortness of breath, palpitations, heart murmur, rheumatic fever, angina, heart attack, or other problems with the heart or circulatory system?
4. Elevated cholesterol, triglycerides or blood sugar?
5. Dizziness, epilepsy, fainting, recurrent headaches, migraines, convulsions, paralysis, stroke or other disorder of the brain or nervous system?
6. Any amputation, partial or total loss of vision, impaired hearing, disease or disorder of the eyes, ears or speech?
7. Asthma, bronchitis, tuberculosis, pneumonia, allergies, emphysema, shortness of breath, blood spitting, persistent cough or other disorder of the lungs or respiratory system, or throat disorder?
8. Skin disorder, including allergies?
9. Cysts, polyps, tumor, cancer or any other growth?
10. Diabetes, thyroid or endocrine disorder?
11. Anemia or any disorder of the blood or bone marrow?
12. Phlebitis, varicose veins, swelling of feet or legs, clotting disorder, or other disorder of blood vessels?
13. Sugar, albumin, protein, blood or pus in urine, nephritis, kidney stone or other disorder of kidney or bladder?
14. Colitis, chronic diarrhea, hernia, ulcer, cirrhosis, or any disease of the digestive system including mouth, esophagus, stomach, u\intestines, rectum, liver, pancreas, or gall bladder?
15. Back, neck or spinal discomfort including pain, sprain, strain, sciatica, disc disease or had therapeutic massage or chiropractic treatment?
16. Arthritis, rheumatism, fibrositis, carpal tunnel syndrome, gout or any other disorder of the muscles, tendons, bones or joints or connective tissue disease?
17. Sexually transmitted disease or any disease or disorder of the reproductive organs?
Other medical history and general information questions:
18. Have you ever had a transfusion of blood or blood products?
19. Have you ever tested positive for hepatitis and/or been told you were a carrier?
20. Have you ever been immunized against Hepatitis B?
21. Have you ever had, been tested, treated, counseled, or had any known indication of, or been told you had: depression, fatigue or burnout, anxiety, stress, chronic fatigue, fibromyalgia, chronic pain syndrome or any other emotional behavioral, mental or nervous disorder?
22. Except prescribed by a physician, have you ever used drugs, barbiturates, narcotics, sedatives, hallucinogens, tranquilizers, L.S.D., cocaine, marijuana or any other addictive substance?
23. Do you now use or have you ever used alcoholic beverages? If "Yes", number of drinks per week: _______
24. Have you ever received or been advised to receive counseling,, treatment or attended an organization because of personal alcohol or substance abuse?
25. During the last 30 days, have you worked in your regular occupation less than your usual number of hours per week because of sickness or injury?
26. Have you ever lost more than 15 days at any one time or been disabled because of accident or illness?
27. Are you now experiencing any symptoms, disease, disorder or condition which might require surgery , impair your health or ability to work (now or in the future) or for which you plan to consult a physician?
28. Are you currently on any medication, prescribed or non-prescribed?
29. Other than already mentioned this application, within the past 5 years, have you consulted a physician, psychiatrist, counselor, marital or family counselor, chiropractor or other health practitioner?
30. Any other condition not covered above? If "Yes", please state condition(s): ________________________________________________________________ ________________________________________________________________ ________________________________________________________________