Initials (The first letters of your first and last name)
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Do you expect to change your country of residence?
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If Yes, provide details, including where you intend to move, when you are moving, why you are moving, and if your occupation is changing tell us what your new occupation will be.
Do you expect to travel outside Canada and the United States within the next 12 months?
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If you DO intend to travel outside Canada and the U.S. within the next 12 months, will you be travelling to a Carribean or Mexican resort for less than four weeks, or travelling by cruise ship?
If your travel plans outside Canada and the U.S. are not to a Carribean or Mexican resort for less than four weeks or by cruise ship, please list the country or city you will visit, your intended length of stay, and the purpose of your travel (Business, Tourism, Visit Family, or Other).
In the last 15 years, have you used or smoked any of the following: Cigarettes, Any form of cannabis (such as hashish), Cigars, a Pipe, Cigarillos, Chewing Tobacco, Nicotine Substitutes (such as gum or patches), E-Cigarettes, or Other (Example: Betel Nuts, Water Pipe)?
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If so, please provide information on which of these products you use or have used, how frequently you use or used them (uses per week), and when you last used them.
In the last 15 years, have you consumed alcohol?
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Do you currently drink alcohol?
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If you do drink alcohol, please provide information on which type of alcohol you consume (wine, beer, or liquor), and how many servings of each you consume, per week.
If you have consumed alcohol in the last 15 years but do not currently drink alcohol, please describe any past drinking behavior, including why you stopped drinking.
In the past 15 years, have you used unprescribed drugs or experimented with drugs or narcotics such as ecstasy, cocaine, LSD, heroin, amphetamines, barbiturates, anabolic steroids or similar agents?
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If you have used the previously described substances in the past 15 years, please provide details, including what you used, how often, and the last time you used it.
Have you ever been treated or counselled for alcohol or drug abuse, or has someone ever recommended that you seek treatment or counselling or reduce your alcohol or drug consumption?
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Do you have a Driver's License?
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In the past two years, have you been charged with any motor vehicle or traffic violation (such as speeding, illegal lane change, or seatbelt violation?
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If you have been charged with any motor vehicle or traffic violation in the past two years, please provide details, including the number of charges and convictions and the date of the last conviction.
In the past five years, have you been charged with careless or dangerous driving or had your licence suspended or revoked?
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If, in the past five years, you have been charged with careless or dangerous driving or had your licence suspended or revoked, provide details, including the number of charges and convictions and the date of the last conviction. In the case of a licence suspension or revocation, provide details, including the date the license was suspended or revoked.
In the past 10 years, have you been charged with refusing a breathalyzer test, or operating a motor vehicle either while impaired by alcohol or drugs or with a blood alcohol level over the legal limit?
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If you HAVE, please provide details, including the number of charges and convictions and the date of the last conviction.
Have you ever had an application for life, disability, critical illness or long term care insurance declined, rated, postponed, cancelled or modified in any way?
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If you HAVE had an application for life, disability, critical illness or long term care insurance declined, rated, postponed, cancelled or modified in any way, please provide details, including the dates, name and type of coverage and the name of the insurance company.
Have you ever been charged with any criminal offence?
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If you have been charged with any criminal offence, please provide details, including the nature of each offence, the date charged, the sentence and the date the sentence and any probation was completed.
In the past five years, have you flown in an aircraft as a pilot or do you expect to fly in an aircraft as a pilot?
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In the past five years, have you participated in a hazardous sport or activity or do you expect to participate in a hazardous sport or activity? Such as: back-country skiing, back-country snowboarding or back-country snowmobiling, ballooning, hang-gliding, heli-skiing, mountain climbing, racing of any kind, scuba or skin diving, skydiving, ultralight flying, or other?
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In the past five years, if you HAVE participated in a hazardous sport or activity or if you expect to do so, WHICH of these sports or activities do you participate in? **Please note that we understand many people in the Bow Valley do participate in one or several of these activities, and the insurance carriers have specific questionnaires related to each of these activities, which we will provide to you.
What is your Height?
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What is your Weight?
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Has your weight changed by more than 10 pounds (4.5 kg) in the past 12 months?
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If your weight HAS changed by more than 10 lbs in the past 12 months, please details, including the amount your weight changed and the reason. If the change resulted from pregnancy, tell us your pre-pregnancy weight.
Do you have a family doctor or clinic that you use regularly?
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What was the date of your last consultation with that doctor or clinic, in-person, by phone, or by internet?
Please provide information on the reason for your last consultation with that doctor or clinic. For instance, some common reasons include routine examination, medical renewal, blood pressure check, etc. Please also provide information on any treatments that were ordered (such as antibiotics, pain medication, anti-inflammatories, etc), and any tests that were ordered (such as blood tests, x-rays, urinalysis, ECG, etc.). Finally, please provide information on the results of those tests (for example, normal function, or abnormal function).
Have you consulted a different doctor or clinic in person, by phone, or by internet, since the consultation listed above?
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If SO, Please provide information on the reason for your last consultation with that doctor or clinic. For instance, some common reasons include routine examination, medical renewal, blood pressure check, etc. Please also provide information on any treatments that were ordered (such as antibiotics, pain medication, anti-inflammatories, etc), and any tests that were ordered (such as blood tests, x-rays, urinalysis, ECG, etc.). Finally, please provide information on the results of those tests (for example, normal function, or abnormal function).
Have either of your parents or a sibling been diagnosed before age 65 with any of the following conditions: heart disease, stroke or cancer?
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If either or both of your parents and/or sibling or siblings have been diagnosed before age 65 with heart disease, stroke, or cancer, please provide details below. Which relative or relatives were disagnosed? What were they disagnosed with? If they were diagnosed with cancer, what type of cancer was it, and where was the cancer located in the body? Finally, how old were they when they were diagnosed?
Have either of your parents or a sibling ever been diagnosed with Huntington's chorea, polycystic kidney disease, Parkinson's disease, multiple sclerosis, Alzheimer's disease, amyotrophic lateral sclerosis (also called ALS or Lou Gehrig's disease) or other motor neuron disease, diabetes, hepatitis, kidney disorders or retinitis pigmentosa?
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If you answered YES, please provide information on which relative or relatives were diagnosed, what they were diagnosed with, and at what age were they diagnosed.
Do you have, have you been treated for, or have you been told you have high blood pressure?
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Do you have, have you been treated for, or have you been told you have High cholesterol?
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Do you have, have you been treated for, or have you been told you have Cancer, tumors, leukemia, polyps, or skin lesions?
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Do you have, have you been treated for, or have you been told you have Diabetes (including gestational diabetes and impaired glucose tolerance)?
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Have you ever had or been told you had or been investigated or treated for conditions involving your heart and blood vessels, such as: angina, blood clots, bypass or angioplasty, cerebrovascular disease (CVA), chest pain or shortness of breath, claudication, heart attack (myocardial infarction), heart disease, heart murmur, pacemaker, palpitations or irregular pulse, peripheral vascular disease or peripheral artery disease, poor circulation, stroke or transient ischemic attack (TIA), swollen ankles (other than due to pregnancy), or other?
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Have you ever had or been told you had or been investigated or treated for conditions involving your nose, throat, or lungs, such as: asthma, chronic bronchitis, chronic obstructive pulmonary disease (COPD), cystic fibrosis, emphysema, sarcoidosis, sleep apnea, tuberculosis, or other?
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Have you ever had or been told you had or been investigated or treated for conditions involving your abdominal organs, such as: celiac disease, cirrhosis, colitis, Crohn's disease, diverticulitis, gastrointestinal bleeding, gastrointestinal reflux, hepatitis (including active or carrier state), hiatus hernia, jaundice, irritable bowel syndrome, liver disease, pancreatitis, ulcer, or other?
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Have you ever had or been told you had or been investigated or treated for conditions involving your kidneys, bladder or reproductive organs, such as: abnormal Pap test, bladder infection, kidney stone, nephritis, polycystic kidney disease, prostatitis or other prostate disorder, protein in the urine, sugar or blood in the urine, urinary tract infection (UTI), uterine fibroids, other kidney or bladder disorders, other reproductive disorder or sexually transmitted disease, or other?
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Have you ever had or been told you had or been investigated or treated for conditions involving your nervous system, such as ALS or other motor neuron disease, Alzheimer's disease, bacterial meningitis, cerebral palsy, cognitive impairment, coma, dementia, developmental delay, dizziness, Down syndrome, epilepsy, fainting or syncope, loss of speech, mental impairment, migraine headaches, multiple sclerosis, paralysis, Parkinson's disease, post-concussion syndrome, seizures or convulsions, tremor, vertigo, or other?
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Have you ever had or been told you had or been investigated or treated for conditions involving your eyes or ears, such as: blindness, blurred or double vision, deafness, glaucoma, impaired hearing, impaired sight, labyrinthitis, optic neuritis, tinnitus, or other?
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Have you ever had or been told you had or been investigated or treated for conditions involving your mental health, such as: anxiety, attempted suicide, burnout, depression, schizophrenia, other psychological, behavioral, emotional or eating disorder, or other?
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Have you ever had or been told you had or been investigated or treated for conditions involving your glands or blood, such as: abnormal blood sugar, anemia, bleeding tendency, gout, hemophilia, lymph glands, thyroid disorders, other endocrine disorders, or other?
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Have you ever had or been told you had or been investigated or treated for conditions involving your muscles or bones, such as: any injury or disorder of the muscles, bones, joints, or spine causing any physical limitations or restrictions, chronic fatigue, chronic pain syndrome, fibromyalgia, muscular dystrophy, rheumatoid arthritis or osteoarthritis, or other?
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Have you ever had or been told you had or been investigated or treated for conditions involving your connective tissue, such as: lupus, scleroderma, or other?
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Have you ever had or been told you had or been investigated or treated for conditions involving your skin, such as: basal cell carcinoma, dermatitis, dysplastic nevus syndrome, dysplastic nevus, nevus or nevi, psoriasis, lesions, freckles or moles that have changed in size, colour, or have bled, or other?
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Have you ever had or been told you had or been investigated or treated for conditions involving your immune system, such as: AIDS, HIV, or other?
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Has anyone ever recommended that you be tested for exposure to AIDS or HIV (other than for routine testing for pregnancy, blood donation, immigration or insurance), or do you have any reason to believe you have been exposed to the virus?
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Section 1/5: For any of the above that you answered YES to, please provide details of each condition or consultation, including: diagnosis if known, treatment history, testing dates, reason for tests, results of tests, recurrence:
Section 2/5: For any of the above that you answered YES to, please provide details of each condition or consultation, including: diagnosis if known, treatment history, testing dates, reason for tests, results of tests, recurrence:
Section 3/5: For any of the above that you answered YES to, please provide details of each condition or consultation, including: diagnosis if known, treatment history, testing dates, reason for tests, results of tests, recurrence:
Section 4/5: For any of the above that you answered YES to, please provide details of each condition or consultation, including: diagnosis if known, treatment history, testing dates, reason for tests, results of tests, recurrence:
Section 5/5: For any of the above that you answered YES to, please provide details of each condition or consultation, including: diagnosis if known, treatment history, testing dates, reason for tests, results of tests, recurrence:
In the past FIVE YEARS, have you had any medical or diagnostic test, such as ECG's, X-rays, CT scans, Pap test, MRI, or blood tests?
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In the past FIVE YEARS, have you had any illness or injury not already mentioned in this application?
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In the past FIVE YEARS, have you used any recommended medication not already mentioned on this form on a daily basis for more than three weeks (including prescription and non-prescription)?
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In the past FIVE YEARS, have you consulted a counselor, health care worker, physician, or therapist?
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Section 1/3: For any of the above that you answered YES to, please provide details of each condition or consultation, including: diagnosis if known, treatment history, testing dates, reason for tests, results of tests, recurrence:
Section 2/3: For any of the above that you answered YES to, please provide details of each condition or consultation, including: diagnosis if known, treatment history, testing dates, reason for tests, results of tests, recurrence:
Section 3/3: For any of the above that you answered YES to, please provide details of each condition or consultation, including: diagnosis if known, treatment history, testing dates, reason for tests, results of tests, recurrence:
During the PAST 12 MONTHS, have you missed more than 15 consecutive days of work or school because of illness or injury?
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Are you currently taking any prescribed medication, herbal or holistic treatment, or are you under observation for any condition other than those you have already told us about?
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Are you currently disabled and unable to perform your regular occupation or regular activities?
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Are you aware of any symptoms or complaints for which you have not consulted a doctor or received treatment?
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Section 1/2: For any of the above that you answered YES to, please provide details of each condition or consultation, including: diagnosis if known, treatment history, testing dates, reason for tests, results of tests, recurrence:
Section 2/2: For any of the above that you answered YES to, please provide details of each condition or consultation, including: diagnosis if known, treatment history, testing dates, reason for tests, results of tests, recurrence:
Do you wear any device or use any application that helps you monitor wellness, health or a specific condition?
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If so, please provide details. What do you wear? Why do you wear it? How long have you been wearing it?
In the past 12 months, have you consulted a doctor or other health practitioner for, been treated for or had any indication of heart attack, cancer, stroke or exposure to AIDS or HIV?
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In the past 60 days, have you consulted a doctor or other health practitioner and been told to have a further examination, diagnostic test or surgery which has not been performed, or for which the results are not known (other than pregnancy or childbirth)?
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What is your annual earned income (within $10,000), including salary, commissions, dividends, bonuses and pension, within Canada?
What is your annual income (within $10,000) from other Canadian sources, including interest and income from real estate, within Canada?
If income is not generated from any of the above sources within Canada, tell us the household income.
What is your personal net worth? To calculate your net worth in Canada, add the value of your Canadian assets (such as cash, investments, personal property and real estate), and deduct your Canadian liabilities (any money you owe such as mortgages, loans and credit cards.)
In the past five years, have the people to be insured or the business had any major financial difficulties, such as having pay garnished, petitioning for bankruptcy or declaring bankruptcy?
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Is a licence or permit required to operate your business?
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If a license or permit IS required to operate your business, has any licence or permit ever been suspended or revoked, or has a regulating agency ever initiated a complaint against you?
Will the money to pay the premiums for this policy be borrowed from an individual, a bank or other institution?
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Is there an existing or planned agreement that provides for anyone other than an owner identified in this application to obtain any legal interest in any policy resulting from this application?
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Section 1/1: If you answered YES to any of the above financial questions, please provide more details in this section.
