Birth Date

Gender

Tobacco use

Yes Tobbacoo Values 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

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%

Underwriting Risk

Elite Preferred Regular Simplified Guaranteed Full Underwriting