Client Information Form

1* Full legal name

2* Date of birth (ie. Jul/10/1979)

3* Gender
MaleFemale

4* Preferred contact phone number

5* Email

6* Preferred contact method
EmailPhone

7 Home address

8 Country of birth

9 Citizenship

10 What is your marital status?
—Please choose an option—Single (no children/dependants)Single (with children/dependants)Married (no children/dependants)Married (with children/dependants)

11* Have you used tobacco products in the last 12 months?
YesNo

12 Have you used marijuana products in the last 12 months?
YesNo
Note: marijuana use may qualify for non-smoker rates.

13 Approximate gross annual household income
—Please choose an option—Under $50,000Between $50,000 - $100,000Between $100,000 - $200,000$200,000 or more

15 Coverage amount desired

16 Policy length desired?
TermPermanentNot sure

18 Describe your health
AverageGoodExcellent

19 Additional Details: (i.e. other health information, details of other existing policies)