Employment Status Salaried Employee Contract Worker Self Employed
Do You Contribute to Unemployment Insurance? Yes No
Do You Contribute to WSIB? No Yes
How Long Have You Been Self-Employed? Less Than 1 Year 1 to 2 Years 3 -5 Years 5 - 10 Years 10+ Years
Hoe Long Have You Been with Your Current Employer? Less Than 1 Year 1 to 2 Years 3 -5 Years 5 - 10 Years 10+ Years
Expected Annual Income $0 - $20,000 $20,000 - $25,000 $25,000 - $30,000 $30,000 - $40,000 $40,000 - $50,000 $50,000 - $65,000 $65,000 - $80,000 $80,000 - $100,000 $100,000 - $125,000 $125,000 - $150,000 $150,000 - $200,000 $200,000 - $250,000 $250,000+ I prefer not to say
Last Years Income $0 - $20,000 $20,000 - $25,000 $25,000 - $30,000 $30,000 - $40,000 $40,000 - $50,000 $50,000 - $65,000 $65,000 - $80,000 $80,000 - $100,000 $100,000 - $125,000 $125,000 - $150,000 $150,000 - $200,000 $200,000 - $250,000 $250,000+ I prefer not to say
What Percentage of Your Income Would You Like to Cover? 10% 20% 30% 40% 50% 60% 70% 80% 90% 100%
Are you currently limited in terms of your movements or your daily activities due to an injury or illness? No Yes
Do you have a chronic neurodegenerative disease or a permanent physical or intellectual impairment? No Yes
In your lifetime, have you suffered from or been treated for AIDS or tested positive for HIV? No Yes
In your lifetime, have you suffered from or been treated for heart attack, angina, heart valve disease, stroke, or any other heart or blood vessel disorders? No Yes
In your lifetime, have you suffered from or been treated for malignant tumour or any other form of cancer (excluding basal cell carcinoma)? No Yes
In your lifetime, have you suffered from or been treated for Crohn’s disease, ulcerative colitis, chronic liver disease, or pancreatitis? No Yes
In your lifetime, have you suffered from or been treated for Polycystic kidney disease or kidney failure? No Yes
In your lifetime, have you suffered from or been treated for diabetes? No Yes
Type 1 or 2 Diabetes? 1 2
In your lifetime, have you suffered from complications as a result of Type 2 diabetes: eye disorders, peripheral nerve damage or kidney disorders? No Yes
Within the last 12 months has your diabetes medication changed as advised by a physician? No Yes
Within the last 5 years, have you suffered from or been treated for asthma which requires daily treatment? No Yes
Within the last 5 years, have you suffered from chronic bronchitis, emphysema, cystic fibrosis, sarcoidosis or sleep apnea? No Yes
Within the last 5 years, have you suffered from or any kidney or genitourinary system disease requiring regular supervision by a physician ? No Yes
Within the last 5 years, have you suffered from or been treated for any type of arthritis (excluding osteoarthritis)? No Yes
Within the last 5 years, have you suffered from any type of lupus, muscular dystrophy or degenerative disc disease, including herniated disc? No Yes
Within the last 12 months has an illness or injury resulted in absence from work for more than two consecutive weeks? No Yes
Presently, do you require regular supervision by your physician or a specialist for all diseases or disorders of the eyes, ears, nose, throat, skin or blood No Yes
Have you been advised to have any tests, follow up on health complications with a physician or undergo surgery, that is still pending? No Yes
Has a member of your immediate family been diagnosed before the age of 60 with breast cancer, ovarian cancer, colon cancer or familial adenomatous polyposis? No Yes
Has a member of your immediate family been diagnosed before the age of 60 with Huntington’s disease or polycystic kidney disease? No Yes
Within the last 5 years, have you used hard drugs or narcotics without a medical prescription? No Yes
Within the last 5 years, have you been treated for drug or alcohol use, or been advised to reduce your consumption or to receive treatment for it? No Yes
Within the last 12 months, have you been convicted of an offence or criminal act, or are you currently under indictment for an offence or criminal act? No Yes
Within the last 12 months, have you has your drivers license has been suspended, withdrawn or restricted (for any reason other than unpaid tickets)? No Yes
