Bestplans Canada: Disability Insurance Quote Form

Disability Insurance Quote Form

Request a free Disability Insurance price quote comparison

General Information

*Indicates required information

Salutation:

*First Name:

*Last Name:

*Address 1:

Address 2:

*City:

*Province:

*PC:

*Home Phone:

Fax:

Business Phone:

*E-Mail:

DOB:

/ /

Website:

Eligibility - Section 1

Do you belong to any of the following occupations?

Yes No

• Actors/actresses/models	• Hazardous materials truck drivers
• Aircraft pilots / instructors / stewards / stewardesses	• Jockey / harness drivers
• Air traffic controllers	• Martial arts instructors
• Armed forces personnel	• Night watchmen
• Authors	• Oil, natural gas industry: all offshore
• Barbers / hairstylists / beauticians / electrolysis	• Power line installers / repairers
• Body-shop employees	• Professional athletes
• Carnival, circus employees / performers / rodeo performers	• Roofers
• Cocktail lounge, nightclub or tavern employees	• Sailors
• Dirvers of: ambulances, tow trucks, rescue vehicles, armoured trucks, logging trucks, taxis, long distance trailer trucks	• Sandblasters
• Entertainers/ musicians/ singers	• Stunt workers
• Fish hatchery or fish processing / packing workers	• Tailors and seamstresses
• Fishermen	• Trappers / hunters
• Gambling industry: all workers	• Unskilled labourers

Eligibility - Section 2

Are you working a minimum of 25 hours a week, at least 35 weeks a year and do you earn a minimum of $12,000 a year?	Yes No

Do you read and speak English or French?	Yes No

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

Are you between the age 18 and 60?	Yes No

Eligibility - Section 3

Within the past 5 years, have you received treatment, been advised to receive treatment or joined an organization because of use of alcohol or non-prescribed drugs or had a drivers licence suspended because of driving while impaired or had 3 or more moving violations?	Yes No

Within the past 5 years, have you been treated for or had any known indication of blindness, deafness, heart attack, stroke or diabetes requiring control by insulin or medication, or any known indication of AIDS or tested positive for exposure to the AIDS virus?	Yes No

Within the past 10 years, have you suffered from, received treatment, medication, medical advice, care, service or diagnosis for, had known indication of, had a positive test for or consulted a physician about dizziness, fainting, convulsions, epilepsy, or disorder of the brain or nervous system?	Yes No

Do you currently suffer from any injury or sickness which prevents or limits you from performing any of the duties of your regular occupation or employment?	Yes No

Are you currently receiving any government benefits such as Employment Insurance (EI), Workers Compensation or any other form of disability benefits?	Yes No

In the last 10 years, have you used any narcotic or other drugs such as cocaine, amphetamines, barbiturates, hallucinogen, sedative, stimulant NOT prescribed by a physician or have you used marijuana or hashish within the last 2 years.	Yes No

Within the past 5 years, have you had any application for Life, Disability or Critical Illness Insurance declined, rated, postponed, canceled or modified in any way?	Yes No

In the last 2 years, have you missed more than 2 consecutive weeks due to sickness or injury?	Yes No

Eligibility - Section 4

Do you have Worker's Compensation (WCB) coverage?

Yes No

Do you belong to any of the restricted occupations?

Yes No

• Blasters and anyone handling explosives or acids	• Mining - underground workers
• Divers and diving attendants	• Ski instructors
• Firemen	• Steeplejacks
• Logging industry: raftsmen, rivermen, river divers, topmen, high climbers, fallers, cutters, buckers, boomsmen, pondmen, boomstick boreers, riggers, chokermen	• Structural iron or steel worker: towers, bridges, buildings over 2 stories, cable cars
• Long Shore Men	• Window cleaners - over 2 stories

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.


Site Map \| Add URL \| Send this page Copyright © Horizon Planning Group Inc. 2000 - 2004 All Rights Reserved