Life Insurance for Everyone Quote Form:
Contact Information:
Family Name:* Mr. Mrs. Ms. Dr. Rev.  
Given Name:
Email Address:*
Mailing Address:
     No. and Street:
     City:
     Province: Select a Province Alberta British Colombia Manitoba New Brunswick Newfoundland Northwest Territories Nova Scotia Nunavut Ontario Prince Edward Island Quebec Saskatchewan Yukon
     Postal Code:
Telephone Numbers:
     Area code:*  Home:*  Office:  Cell:

Tell Us About Yourself:
Marital Status: Select Marital Status married with children married with no children divorced widow(er) single common law
Number of dependent children:
Gender: Select Gender male female
Birth date: day  month Select Month January February March April May June July August September October November December   Year
Smoking Status: Select Smoking Status non smoker - lifetime non smoker for 5 years non smoker for 2 years non smoker for 12 months smoker smoker - cigarettes only smoker - pipe, cigar only
Height:  inches     OR     cm
Weight: pounds    OR     kg
Occupation:
Please list medications and reasons to help assess insurance risk category:


Your Insurance Needs:
Purpose of the Insurance:
Select the Insurance Purpose Income Replacement Mortgage Pension Maximization Estate Taxes Burial and Final Expenses Savings Plan Family Protection Replacing Group Coverage Replacing Existing Coverage for Better Rate

Please select a Life Insurance Plan:
Amount of Life Insurance coverage:
Select the Coverage Amount $10,000 $25,000 $50,000 $100,000 $250,000 $500,000 $750,000 $1,000,000 other - see form      OR     Other $
Life Insurance Plan: 
Select a Life Insurance Plan Term - 5 yrs Term - 10 yrs Term - 15 yrs Term - 20 yrs Term - 25 yrs Term - 30 yrs Term - 65 yrs Term - 75 yrs Term 100 - life pay Term 100 - 20 pay -------------------- Whole Life - participating - life pay Whole Life - participating - 20 pay Whole Life - non participating - life pay Whole Life - non participating - 10 pay Whole Life - non participating - 20 pay Whole Life - non participating - 10 age 65 pay -------------------- Universal Life - Level cost of insurance Universal Life - Term 10 cost of insurance Universal Life - Yearly cost of insurance
Please add any other relevant information to help assess insurance risk (i.e. occupation, avocations).
Also use this area for any questions or comments.


Please select from our many other insurance plans:
Non Medical Insurance Plans:
Select a Non Medical Insurance Plan Guaranteed Life Plans - non medical Final Expense Plan - non medical
Travel Insurance Plans:
Select a Travel Insurance Plan Visitor to Canada Travel Plan for Canadians Expatriate Plans Interim Provincial Health Plan Replacement Special Request Plans
Health and Dental Plans:
Select a Health and Dental Insurance Plan Hospital Plan Dental Plan Drug Plan Health Plan Comprehensive Plan
Business Insurance Plans:
Select a Business Insurance Plan Key Man Insurance Buy & Sell Agreement Insurance Split Dollar Insurance
Living Benefits Insurance Plans:
Select a Living Benefits Plan Critical Illness Insurance Disability Insurance Long Term Care Insurance

The independent life brokers at "Life Insurance for Everyone" thank you for your interest in our products and we look forward to serving you.  If you have any questions please feel free to call us at (613) 228-5433.