Client Name 
			
			 
	 
	
			Client Phone 
			
			 
	 
	
			Client Email 
			
			 
	 
		
			Age  
			
				Last  
		 
			
				Birth Date 
				
					
						January
						 February
						 March
						 April
						 May
						 June
						 July
						 August
						 September
						 October
						 November
						 December
					  
					
						1
						 2
						 3
						 4
						 5
						 6
						 7
						 8
						 9
						 10
						 11
						 12
						 13
						 14
						 15
						 16
						 17
						 18
						 19
						 20
						 21
						 22
						 23
						 24
						 25
						 26
						 27
						 28
						 29
						 30
						 31
					  
					
       				  1917 
					  1918 
       				  1919 
					  1920 
    				  1921 
					  1922 
       				  1923 
					  1924 
					  1925 
					  1926 
       				  1927 
					  1928 
       				  1929 
					  1930 
    				  1931 
					  1932 
       				  1933 
					  1934 
                      1935 
					  1936 
       				  1937 
					  1938 
       				  1939 
					  1940 
    				  1941 
					  1942 
       				  1943 
					  1944 
					  1945 
					  1946 
       				  1947 
					  1948 
       				  1949 
					  1950 
    				  1951 
					  1952 
       				  1953 
					  1954 
					  1955 
					  1956 
       				  1957 
					  1958 
       				  1959 
					  1960 
    				  1961 
					  1962 
       				  1963 
					  1964 
					  1965 
					  1966 
       				  1967 
					  1968 
       				  1969 
					  1970 
    				  1971 
					  1972 
       				  1973 
					  1974 
					  1975 
					  1976 
       				  1977 
					  1978 
       				  1979 
					  1980 
    				  1981 
					  1982 
       				  1983 
					  1984 
                      1985 
					  1986 
       				  1987 
					  1988 
       				  1989 
					  1990 
    				  1991 
					  1992 
       				  1993 
					  1994 
					  1995 
					  1996 
       				  1997 
					  1998 
       				  1999 
					  2000 
    				  2001 
					  2002 
       				  2003 
					  2004 
					  2005 
					  2006 
       				  2007 
					  2008 
       				  2009 
					  2010 
    				  2011 
					  2012 
       				  2013 
					  2014 
        			  2015 
        			  2016 
        			  2017 
    				  2018 
					  2019 
       				  2020 
					  2021 
        			  2022 
        			  2023         			  
                     
			 
		 
			
				Gender 
				
					 
			 
        	
			Tobacco use (Ever?) 
				
                
                
                
                 
			 		
            
            
				  
				
					
					
						
						
							Cigarette
							 Never
							 within 12 months
							 more than 1 yr ago
							 more than 2 yrs ago
							 more than 3 yrs ago
							 more than 4 yrs ago
							 more than 5 yrs ago
							 more than 6 yrs ago
							 more than 10 yrs ago
							 more than 15 yrs ago
							 more than 25 yrs ago
						  
						
							Cigar
							 Never
							 within 12 months
							 more than 1 yr ago
							 more than 2 yrs ago
							 more than 3 yrs ago
							 more than 4 yrs ago
							 more than 5 yrs ago
							 more than 6 yrs ago
							 more than 10 yrs ago
							 more than 15 yrs ago
							 more than 25 yrs ago
						  
						 
					 
					
						
						
							Cigarello
							 Never
							 within 12 months
							 more than 1 yr ago
							 more than 2 yrs ago
							 more than 3 yrs ago
							 more than 4 yrs ago
							 more than 5 yrs ago
							 more than 6 yrs ago
							 more than 10 yrs ago
							 more than 15 yrs ago
							 more than 25 yrs ago
						  
						
							Pipe
							 Never
							 within 12 months
							 more than 1 yr ago
							 more than 2 yrs ago
							 more than 3 yrs ago
							 more than 4 yrs ago
							 more than 5 yrs ago
							 more than 6 yrs ago
							 more than 10 yrs ago
							 more than 15 yrs ago
							 more than 25 yrs ago
						  						
						 
					 
					
																								
						
							Chew
							 Never
							 within 12 months
							 more than 1 yr ago
							 more than 2 yrs ago
							 more than 3 yrs ago
							 more than 4 yrs ago
							 more than 5 yrs ago
							 more than 6 yrs ago
							 more than 10 yrs ago
							 more than 15 yrs ago
							 more than 25 yrs ago
						  
						
							Other
							 Never
							 within 12 months
							 more than 1 yr ago
							 more than 2 yrs ago
							 more than 3 yrs ago
							 more than 4 yrs ago
							 more than 5 yrs ago
							 more than 6 yrs ago
							 more than 10 yrs ago
							 more than 15 yrs ago
							 more than 25 yrs ago
						  
						 
					 
					
						
						
							Marijuana
							 Never
							 within 12 months
							 more than 1 yr ago
							 more than 2 yrs ago
							 more than 3 yrs ago
							 more than 4 yrs ago
							 more than 5 yrs ago
							 more than 6 yrs ago
							 more than 10 yrs ago
							 more than 15 yrs ago
							 more than 25 yrs ago
						  
						
							Vapor / E-Cigarette
							 Never
							 within 12 months
							 more than 1 yr ago
							 more than 2 yrs ago
							 more than 3 yrs ago
							 more than 4 yrs ago
							 more than 5 yrs ago
							 more than 6 yrs ago
							 more than 10 yrs ago
							 more than 15 yrs ago
							 more than 25 yrs ago
						  
						 
					 
					
						
						
							Water / Spritual Pipe
							 Never
							 within 12 months
							 more than 1 yr ago
							 more than 2 yrs ago
							 more than 3 yrs ago
							 more than 4 yrs ago
							 more than 5 yrs ago
							 more than 6 yrs ago
							 more than 10 yrs ago
							 more than 15 yrs ago
							 more than 25 yrs ago
						  						
						 
					 
				
			 
		 
        
            	
			
				Province 
				
					
						British Columbia
                         Alberta
                         Saskatchewan
                         Northwest Territories
                         Yukon Territory
                         Nunavit
                         Manitoba
                         Ontario
                         Quebec
                         Nova Scotia
                         New Brunswick
                         Prince Edward Island
                         Newfoundland
                       All Provinces
					  
				 
			             
			
				Face Amount 
				
					
						Face Amount
						 $ 5,000
						 $ 10,000
						 $ 15,000
						 $ 20,000						
						 $ 25,000
						 $ 30,000
						 $ 35,000
						 $ 40,000
						 $ 45,000
						 $ 50,000
						 $ 55,000
						 $ 60,000
						 $ 65,000
						 $ 70,000
						 $ 75,000
						 $ 80,000
						 $ 85,000
						 $ 90,000
						 $ 95,000
						 $ 100,000
						 $ 125,000
						 $ 150,000
						 $ 175,000
						 $ 200,000
						 $ 225,000
						 $ 250,000
						 $ 275,000
						 $ 300,000
						 $ 325,000
						 $ 350,000
						 $ 375,000
						 $ 400,000
						 $ 425,000
						 $ 450,000
						 $ 475,000
						 $ 500,000
						 $ 550,000
						 $ 600,000
						 $ 650,000
						 $ 700,000
						 $ 750,000
						 $ 800,000
						 $ 850,000
						 $ 900,000
						 $ 950,000
						 $1,000,000
						 $1,250,000
						 $1,500,000
						 $1,750,000
						 $2,000,000
						 $2,250,000
						 $2,500,000
						 $2,750,000
						 $3,000,000
						 $3,500,000
						 $4,000,000
						 $4,500,000
						 $5,000,000
						 $6,000,000
						 $7,000,000
						 $8,000,000
						 $9,000,000
						 $10,000,000
						 $11,000,000
						 $12,000,000
						 $13,000,000
						 $14,000,000
						 $15,000,000
						 $16,000,000
						 $17,000,000
						 $18,000,000
						 $19,000,000
						 $20,000,000
						 $21,000,000
						 $22,000,000
						 $23,000,000
						 $24,000,000
						 $25,000,000
						 $26,000,000
						 $27,000,000
						 $28,000,000
						 $29,000,000
						 $30,000,000
                      
				 
			          
            
				Premium Payment 
									
					
						Premium mode
						 Annual
						 Semi-Annual
						 Quarterly
						 Monthly
					  
				 
			   
			
				Product Type 
				
					
						1 year Term
						 5 year Term
					  	 10 year Term
   					  	 15 year Term
   					  	 20 year Term
                         25 Year Term
                         30 Year Term
                         35 Year Term
                         40 Year Term
                         Level term to 65
                         Level term to 70
                         Level term to 75
                         Unique Term
                         OptiTerm
                         Traditional Term 100
                         T100 20-Pay
                         Unique Term 100
                         Whole Life / Life Pay
                         Whole Life / Pay to 65
                         Whole Life / 25 Pay
                         Whole Life / 20 Pay
                         Whole Life / 15 Pay
                         Whole Life / Quick Pay
                         Unique Whole Life
                         Universal Life / T100 Min. Premium
                         Living Benefits
                         Single Person Funeral Plan
                      
                    
                    
					  	5 year Term
   					  	 6 year Term
                         7 Year Term
                         8 Year Term
                         9 Year Term
                        
                         10 year Term
   					  	 11 year Term
   					  	 12 year Term
                         13 Year Term
                         14 Year Term
                         15 Year Term
                         16 Year Term
                         17 Year Term
                         18 Year Term
                         19 Year Term
                        
                         20 year Term
   					  	 21 year Term
   					  	 22 year Term
                         23 Year Term
                         24 Year Term
                         25 Year Term
                         26 Year Term
                         27 Year Term
                         28 Year Term
                         29 Year Term
                         30 year Term
   					  	 31 year Term
   					  	 32 year Term
                         33 Year Term
                         34 Year Term
                         35 Year Term
                         36 Year Term
                         37 Year Term
                         38 Year Term
                         39 Year Term
                         40 year Term
                         41 year Term
   					  	 42 year Term
                         43 Year Term
                         44 Year Term
                         45 Year Term
                         46 Year Term
                         47 Year Term
                         48 Year Term
                         49 Year Term
                         50 year Term
                      
					
					  	CI / Term 10
   					  	 CI / Term 15
   					  	 CI / Term 20
                         CI / Term 25
                         CI / Term 30
                         CI / Term 65
                         CI / Term 70
                         CI / Term 75
                         CI / T100 - Life Pay
                         CI / T100 - Pay to 65
                        
                         CI / T100 - 10-20 Pay
   					  	 CI / Cond. limited Pay
   					  	 CI / Decreasing
                         Comb Life & CI/25%
                         Comb Life & CI/50%
                         Comb Life & CI/75%
                      
				 
			 
			
 				Select the Critical Illnesses that need to be covered by the quoted products:  
			
			
				Underwriting Risk 
				
							
								Elite
								 Preferred
								 Regular
								 Simplified
								 Guaranteed