Single Insured
Gender
Male
Female
Tobacco Use
Yes
No
Tobacco Use / Habits
Never
within 12 months
more than 1 yr ago
more than 2 yrs ago
more than 3 yrs ago
more than 4 yrs ago
more than 5 yrs ago
more than 6 yrs ago
more than 10 yrs ago
more than 15 yrs ago
more than 25 yrs ago
Cigarette
Never
within 12 months
more than 1 yr ago
more than 2 yrs ago
more than 3 yrs ago
more than 4 yrs ago
more than 5 yrs ago
more than 6 yrs ago
more than 10 yrs ago
more than 15 yrs ago
more than 25 yrs ago
Cigar
Max. use per any month
Total use in last year
Never
within 12 months
more than 1 yr ago
more than 2 yrs ago
more than 3 yrs ago
more than 4 yrs ago
more than 5 yrs ago
more than 6 yrs ago
more than 10 yrs ago
more than 15 yrs ago
more than 25 yrs ago
Cigarello
Never
within 12 months
more than 1 yr ago
more than 2 yrs ago
more than 3 yrs ago
more than 4 yrs ago
more than 5 yrs ago
more than 6 yrs ago
more than 10 yrs ago
more than 15 yrs ago
more than 25 yrs ago
Pipe
Never
within 12 months
more than 1 yr ago
more than 2 yrs ago
more than 3 yrs ago
more than 4 yrs ago
more than 5 yrs ago
more than 6 yrs ago
more than 10 yrs ago
more than 15 yrs ago
more than 25 yrs ago
Chew
Never
within 12 months
more than 1 yr ago
more than 2 yrs ago
more than 3 yrs ago
more than 4 yrs ago
more than 5 yrs ago
more than 6 yrs ago
more than 10 yrs ago
more than 15 yrs ago
more than 25 yrs ago
Marijuana
Max. use per any week
Max. use per any month
Total use in last year
Any smoked Marijuana mixed with tobacco?
Yes
No
Never
within 12 months
more than 1 yr ago
more than 2 yrs ago
more than 3 yrs ago
more than 4 yrs ago
more than 5 yrs ago
more than 6 yrs ago
more than 10 yrs ago
more than 15 yrs ago
more than 25 yrs ago
Other
Never
within 12 months
more than 1 yr ago
more than 2 yrs ago
more than 3 yrs ago
more than 4 yrs ago
more than 5 yrs ago
more than 6 yrs ago
more than 10 yrs ago
more than 15 yrs ago
more than 25 yrs ago
Vape
Never
within 12 months
more than 1 yr ago
more than 2 yrs ago
more than 3 yrs ago
more than 4 yrs ago
more than 5 yrs ago
more than 6 yrs ago
more than 10 yrs ago
more than 15 yrs ago
more than 25 yrs ago
Water & Sacramental Pipes
Max. use per any month
Total use in last year
Birth Date
Age Last
Nearest
Elite
Preferred
Regular
Simplified
Guaranteed
Health
Face Amount ($)
1 year Term
5 year Term
10 year Term
15 year Term
20 year Term
25 Year Term
30 Year Term
35 Year Term
40 Year Term
Level term to 65
Level term to 70
Level term to 75-80
Unique Term
OptiTerm
Term to 100
Term to 100 20 Pay
Unique T100
Whole Life / Life Pay
Whole Life / Pay to 65
Whole Life / 25 Pay
Whole Life / 20 Pay
Whole Life / 15 Pay
Whole Life / Quick Pay
Unique Whole Life
Universal Life / T100 Min. Premium
Living Benefits
Single Person Funeral Plan
Plan Group
5 year Term
6 year Term
7 Year Term
8 Year Term
9 Year Term
10 year Term
11 year Term
12 year Term
13 Year Term
14 Year Term
15 Year Term
16 Year Term
17 Year Term
18 Year Term
19 Year Term
20 year Term
21 year Term
22 year Term
23 Year Term
24 Year Term
25 Year Term
26 Year Term
27 Year Term
28 Year Term
29 Year Term
30 year Term
31 year Term
32 year Term
33 Year Term
34 Year Term
35 Year Term
36 Year Term
37 Year Term
38 Year Term
39 Year Term
40 year Term
41 year Term
42 year Term
43 Year Term
44 Year Term
45 Year Term
46 Year Term
47 Year Term
48 Year Term
49 Year Term
50 year Term
OptiTerm Item
CI / Term 10
CI / Term 15
CI / Term 20
CI / Term 25
CI / Term 30
CI / Term 65
CI / Term 70
CI / Term 75
CI / T100 - Life Pay
CI / T100 - Pay to 65
CI / T100 - 10-20 Pay
CI / Cond. limited Pay
CI / Decreasing
CI / Unique
Living Benefit Item
Sufficiency Filter
Sufficieny Filter
Critical Illness products vary significantly in terms of the critical diseases and conditions covered.
Use the Sufficieny Filter, where you would indicate the illnesses/conditions that must be covered by each of the policies to be quoted.
Select the Critical Illnesses that need to be covered by the quoted products:
Return of Premium
at Death
on Surrender
on Expiry at Maturity
Heart Attack
Cancer
Stroke
Acquired Brain Injury
Alzheimer's Disease
Aortic Surgery
Aplastic Anaemia
Autisom
Bacterial Meningitis
Benign Brain Tumour
Blindness
Cerebral Palsy
Coma
Congenital Heart Disease
Coronary Angioplasty
Coronary Artery Surgery
Cystic Fibrosis
Deafness
Heart Valve Replacement
Kidney (Renal) Failure
Loss of Independence
Loss of Limbs
Loss of Speech
Major/Vital Organ Failure/Transplant
Motor Neuron /Lou Gehrig's Disease
Multiple Sclerosis
Muscular Dystrophy
Occupational HIV
Paralysis
Parkinson's Disease
Rett Syndrome
Severe Burns
Type 1 Diabetes Mellitus