Bestplans Canada:

Critical Illness Insurance Quote Form

Request a free Critical Illness Insurance price quote comparison

General Insured Information Fields marked with an * are required fields.
Salutation:		Gender:	Male Female
*First Name:		*Last Name:
*Address 1:		Address 2:
*City:		*Province:	*PC:
*Phone:		Fax:
*Email:		DOB:	/ /
Height:	' " ft cm	Weight:	lbs kg


*Eligibility (Required but not mandatory)*
Are you between the age 18 and 60?			Yes No

Do you read and speak English or French?			Yes No

Are you a Canadian citizen or do you have your landed Immigrant Status?			Yes No

Within the past 5 years, have you had any application for Life, Disability or Critical Illness insurance declined, postponed, cancelled, rescinded, rated, modified or issued other than applied for in any way?			Yes No

Within the past 5 years, have you had any abnormal diagnostic test results including mammograms or abnormal PSA test for prostate cancer; or have you consulted, received treatment or advice from or been prescribed medication by any medical advisor for tumours, polyps, chest pain, palpitations, TIA's (transient Ischemic attacks), diabetes, kidney disease, eye (excluding corrective lenses) or ear disorder, or hepatitis or any disorder of the liver or colon, AIDS or positive HIV test?			Yes No

Are you aware of any symptoms or complaints regarding your health for which you have not yet consulted a physician or received treatment?			Yes No

Have you been advised to have further examination, diagnostic testing, treatment or surgery that has not yet been scheduled or completed?			Yes No

Have any of your immediate family members (father, mother, siblings) had breast or colo-rectal cancer, heart disease, polycystic kidney disease or stroke prior to age 60?			Yes No


Smoking and Drug Use Status
Have you used any form of tobacco in the last 12 months, including cigarettes, cigarillos, cigars, pipes, chewing tobacco or smoking cessation products such as nicorette gum or nicotine patch or have you used any marijuana or hashish in the last 12 months?			Yes No

Comments:


Our Privacy Policy:

Horizon Planning Group Inc. values your business and we thank you for your confidence in choosing our firm as your source of advice and products. As our client, you trust us with your personal information. We respect that trust and want you to be aware of our commitment to protect the information you share in the course of doing business with us. To learn more, please read our entire Privacy Policy. * Yes, I agree to Horizon Planning Groups use of my above personal information to obtain my requested quotation.


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