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Client Name Client Phone Client Email Age Last Nearest 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 Male Female Tobacco use (Ever?) Yes No   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 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: Heart Attack Cancer Stroke Acquired Brain Injury Alzheimer's Disease Aortic Surgery Aplastic Anaemia Autism Bacterial Meningitis Benign Brain Tumour Blindness Cerebral Palsy Coma Congenital Heart Disease Coronary Angioplasty Coronary Artery Surgery Cystic Fibrosis Deafness Heart Valve Replacement Kidney (Renal) Failure Loss of Independence Loss of Limbs Loss of Speech Major/Vital Organ Failure/Transplant Motor Neuron /Lou Gehrig's Disease Multiple Sclerosis Muscular Dystrophy Occupational HIV Paralysis Parkinson's Disease Rett Syndrome Severe Burns Type 1 Diabetes Mellitus Underwriting Risk Elite Preferred Regular Simplified Guaranteed

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