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Critical Illness Insurance

Name:
Address:
City:
Province:
Postal Code:	(X1Y 2Z3)
Phone Number:	(123-456-7890)
Email Address:	(xxx@yyyy.zzz)
#1   #2 Insured's Name: Date of Birth: Tobacco Use: Select Never Quit < 12 months ago Quit 1-5 years ago Quit > 5 years ago Currently smoke Only cigars/pipe Marijuana use   Select Never Quit < 12 months ago Quit 1-5 years ago Quit > 5 years ago Currently smoke Only cigars/pipe Marijuana use Amount of Insurance: Sex: Select Male Female   Select Male Female Health: Select Excellent Good Fair Poor   Select Never Excellent Good Fair Poor   Note: Excellent: trim/athletic, no medications Good: No infirmities, no medications Fair: Slightly overweight or taking medications Poor: Have or had a serious health condition
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