Do you have any other pending insurance applications?
Have you ever been declined for insurance?
Do you have any in-force insurance (excluding group or credit insurance)?
Last time you used tobacco in any form (cigarettes, cigars, e-cigarettes, cannabis mixed with tobacco, gum, patches, chewing tobacco, snuff, betel nuts, shisha, hookah, etc.)?
3
Personal Background
Were you born in Canada?
Have you lived in Canada for 3 years or more?
Have you lived in Canada for 1 year or more?
In the last 12 months, have you submitted a declaration of insurability (application, paramedical exam, phone interview) to IA?
4
Beneficiaries
Primary Beneficiary
Beneficiary 1
Contingent Beneficiary
Contingent 1
5
Regulatory Questions
Will the life insurance premiums be financed or paid by a lender or any other person with no relationship to the insured?
Is the applicant a U.S. resident for U.S. tax purposes?
Is the applicant a tax resident in a jurisdiction other than Canada or the United States?
6
Billing — Pre-Authorized Debit (PAC/PAD)
Do you already pay by PAC or PAD?
Banking Information
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