Name

First

Last

Date of Birth

Gender

Phone

Height

Weight

Are you a Canadian citizen or a permanent resident?

Do you currently live in Canada?

In the past 12 months, have you had an insurance application declined or postponed?

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Health Questionnaire

Do you have existing individual life insurance insurance?

Has a physician informed you that you have less than 2 years to live?

In the last month, have you been diagnosed with COVID-19 or been in contact with an individual confirmed to have COVID-19?

Are you currently confined to a wheelchair, bedridden, hospitalized or do you need full-time care?

In your lifetime, have you ever had symptoms, been diagnosed or treated for stroke or transient cerebral ischemia (ICT)?

In your lifetime, have you ever had symptoms, been diagnosed or treated for heart attack, heart or coronary artery surgery, chest pain (angina), arrhythmia or any other disease of the heart or blood vessels?

In your lifetime, have you ever had symptoms, been diagnosed or treated for cancer or malignant thyroid tumor?

In your lifetime, have you ever had symptoms, been diagnosed or treated for cancer or malignant tumor other than thyroid cancer and basal cell carcinoma?

In your lifetime, have you ever had symptoms, been diagnosed or treated for type 1 (insulin-dependent) diabetes?

In your lifetime, have you ever had symptoms, been diagnosed or treated for type 2 diabetes?

In your lifetime, have you ever had symptoms, been diagnosed or treated for hepatitis B or C, cirrhosis, liver failure, chronic pancreatitis?

In your lifetime, have you ever had symptoms, been diagnosed or treated for renal failure, polycystic kidney disease, any other chronic kidney disease?

In your lifetime, have you ever had symptoms, been diagnosed or treated for anemia or other blood disorder causing embolism, phlebitis and recurrent thrombosis?

In your lifetime, have you ever had symptoms, been diagnosed or treated for schizophrenia, bipolar illness, psychosis, suicide attempt or hospitalization for any psychological disorder?

In your lifetime, have you ever had symptoms, been diagnosed or treated for systemic lupus, muscular dystrophy, Alzheimer's disease, Parkinson's disease, memory loss, loss of balance, multiple sclerosis, amyotrophic lateral sclerosis (ALS) or any other neurological disorder?

In your lifetime, have you ever had an HIV test with a positive result?

In your lifetime, have you ever had symptoms, been diagnosed or treated for ulcerative colitis or crohn's disease?

In the past 3 years, have you had symptoms, been diagnosed or treated for a respiratory or pulmonary disorder (other than asthma, colds, flu or bronchitis, treated sleep apnea, pneumonia)?

In the past 12 months, have you been told of an abnormal medical test result?

In the last 12 months, have you been absent from work for more than 1 month for a psychological disorder or was your medication for a psychological disorder increased?

Have you consulted a doctor for a disease or disorder that has not yet been diagnosed or for which tests are in progress or not completed? Are you awaiting an investigation, result or operation?

Do you have any symptoms or health problems for which you have not yet consulted a doctor?

Have any of your family members, father, mother, brother or sister ever suffered from familial adenomatous polyposis (or Gardner's disease), Lynch syndrome, Huntington's disease or polycystic kidney disease ?

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Disclosure

All quotes are provided by Red Helm Insurance Ltd. FSRA license #37440M, an independent brokerage specializing in health benefits. While all effort is made to ensure accuracy, quotes, rates, and plan details may be subject to review or change without prior notice. Plan eligibility is not guaranteed and may be subject to a medical questionnaire or other eligibility criteria. By submitting your information in our quote request form, you are accepting the terms and conditions of our website and are accepting that we communicate with you electronically for the purpose of solicitation. This is not an application for health or life insurance. It is used by your Red Helm Insurance advisor to help you determine which plan is most suitable for you. Your health information will not be shared with any 3rd party and is strictly used to provide advice related to the application of life or health insurance.

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