Request for Solo Quote

INSURED PERSON'S INFO Insured Person's Name: Email: Telephone: Fax: Mailing Address: Province of Residence: Country: Postal Code: Please Contact me by: Telephone   Fax   Email Date of Birth (MM/DD/YR) Gender: I am a non-smoker: Male Female Yes No Insured's Occupation & Duties Insurable GROSS Annual Income ------------------------------------------------------------------- SPOUSE (TO BE COVERED) INFO Spouse to be covered YES NO Name of spouse Province of residence Date of Birth (MM/DD/YR) Gender: I am a non-smoker: Male Female Yes No Spouse's Occupation & Duties ------------------------------------------------------------------- LIFE INSURANCE COVERAGE $20,000 or $ Accident Insurance Coverage desired: $ None or $ Spouse's Life Insurance Coverage desired: $ None or $ Spouse's Accident Insurance Coverage desired: $ None or $ Children's Insurance Coverage desired: $ None or $5,000 or $10,000 ------------------------------------------------------------------- DISABILITY INCOME REPLACEMENT Coverage desired: $None or $ per month Better Definition of Disability to last: 24 months 60 months or to age 65 Disability Benefits to begin after: 14 days 30 days 60 days or 120 days Disability Benefit Period to last: 5 years or to age 65 Are you covered by Workers Compensation? Yes No ------------------------------------------------------------------- EXTENDED HEALTH CARE, DRUG CARD & DENTAL Yes No Annual Deductible: $50 single, $100 family - Expense Reimbursement of 80% $500 one time only - Expense Reimbursement of 100% $5 user pay drug card - Expense Reimbursement of 80% $50, $100 family - Expense Reimbursement of 100% ------------------------------------------------------------------- DENTAL COVERAGE to be added to Extended Health? Yes No Dental for Single (1 Individual only) Dental for Couple (2 adult persons only) Dental for Single Parent (with children under age 19) Dental for Family (2 parents with children under age 19) ------------------------------------------------------------------- BUSINESS EXPENSE REIMBURSEMENT - when disabled? Yes No Monthly Business Expense Disability coverage desired: $ Monthly Business Expense Reimbursement to begin after: 30 days 120 days