Health Questionnaire

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Child's Term Life Rider

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Mortgage Disability Rider

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Guaranteed Insurability Rider

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Disability Waiver of Premium

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01.

Please Confirm Your email

02.

Are you a Canadian Citizen or Permanent Resident?

Choose an option:

Yes

No

You would not qualify based on this answer

03.

Do you have any pending medical tests or ongoing investigations?

Choose an option:

Yes

No

You would not qualify based on this answer

04.

Have you ever been treated or diagnosed with AIDS or HIV?

Choose an option:

Yes

No

You would not qualify based on this answer

05.

In the past 10 years have you been convicted of a criminal charge For which you have not been granted a pardon for?

Choose an option:

Yes

No

You would not qualify based on this answer

06.

Have you used illicit drugs (other than marijuana) in the last 10 years?

Choose an option:

Yes

No

You would not qualify based on this answer

07.

Have you ever been diagnosed or treated for: Major Depression, Bi-Polar Disorder, Self-Harm or Schizophrenia?

Choose an option:

Yes

No

You would not qualify based on this answer

08.

Do you have any unknown symptoms for which you have not consulted with medical professional?

Choose an option:

Yes

No

You would not qualify based on this answer

09.

Do You Have any plans or Intentions to change your Country of residency in the next 12 months?

Choose an option:

Yes

No

You would not qualify based on this answer

10.

Have you ever been treated or received counselling for the abuse of drugs or alcohol?

Choose an option:

Yes

No

You would not qualify based on this answer

11.

Have you ever had any heart or blood vessel conditions?

Such as:

Heart Disease
Heart Attack
Chest Pain
Transient Ischemic Attack (TIA)
Stroke
Aneurysm
Heart Murmur
Abnormal ECG or Cardiac Tests
Irregular Heartbeat or Blood Clots

Choose an option:

Yes

No

12.

have you ever had any brain or nervous system conditions?

Such as:

Epilepsy
Multiple Sclerosis
Seizures
ALS
Optic Neuritis
Muscular Dystrophy
Memory Loss
Dementia
Parkinson's
Numbness or Head Injuries

Choose an option:

Yes

No

13.

Have you ever had any lung conditions?

Such as:

TB
Emphysema
COPD
Sleep Apnea
Asthma (excluding childhood Asthma or non-smokers with mild/seasonal Asthma)

Choose an option:

Yes

No

14.

Have you ever had any liver conditions?

Such as:

Cirrhosis
Positive for Hepatitis B or C

Choose an option:

Yes

No

15.

Have you ever had any kidney or bladder conditions?

Such as:

Blood or Protein in Urine
Bladder (excluding resolved bladder infections)
Pancreas disorder
Esophagus disorder
Intestines or Colon such as Colon Polyps
Crohn's Disease or Ulcerative Colitis

Choose an option:

Yes

No

16.

have you ever had any form of diabetes?

Choose an option:

Yes

No

17.

have you ever had any form of cancer?

Choose an option:

Yes

No

18.

Have you ever been treated for or had any known indication of:

Such as:

Major depression, bipolar disorder, self-harm or schizophrenia
Any mental health condition, including stress or anxiety, which have required hospitalization or time off work/school anytime in the past
Any treatment with medication in the past 2 years for anxiety/depression/stress

Choose an option:

Yes

No

19.

Have you ever been advised that you should be treat for, or that you had the following:

Such as:

Elevated cholesterol
High blood pressure

Choose an option:

Yes

No

20.

Have you had more than 2 weeks off work or school in the past 24 months for health reasons?

You do not need to tell us about time off work for pregnancy or for a muscle or bone injury which you have fully recovered from.

Choose an option:

Yes

No

21.

Have any of your immediate biological family members been diagnosed with the following before they were 65?

This only includes parents or siblings

Such as:

Heart Disease or Stroke
Any type of Cancer
Polycystic Kidney Disease (PKD)
Huntington’s Disease or Cardiomyopathy

Choose an option:

Yes

No

22.

How many alcoholic beverages do you consume on a weekly basis?

Enter an amount:

23.

How Many license suspensions, DUI or moving violations (speeding, cell phone tickets) in the past 5 years?

Enter an amount:

24.

Do you participate or intend to participate in any dangerous hobbies or sports?

Such as:

Flying as a pilot, student pilot or crew member on any type of aircraft
Motorized racing (car, motorcycle, snowmobile, etc)
Rock or ice climbing
Scuba diving
Heli skiing/snowboarding or any back-country activities including skiing snowboarding/snowboarding
Any other high-risk activities

Choose an option:

Yes

No

25.

Are you a pilot or crew member for an aviation company?

Choose an option:

Yes

No

26.

Within the next 12 months do you have any flights or accommodations booked for travel outside of Canada or The US?

Choose an option:

Yes

No

27.

Have you ever been Declined for life insurance in the past?

Choose an option:

Yes

No

28.

Please tell us what your job or business is

Thank You For Applying

Congratulations on taking the first steps to securing your loved one’s financial futures. The next step is to schedule a Verification Call with one of our dedicated team members. We will need to verify your identity and finalize your application. We will contact you directly within the same business day if you have submitted your application Mon-Fri before 5 PM PST and the next business day on holidays and weekends. If you would like to schedule a call now, please use this button below

Schedule A Call

Plan:

Empire Life Insurance

Premium Amount:

$39.99

Coverage AMount

$1,200,000

Term (Years)

25 Years

Additional Options:

Please choose an Optional Rider(s). We can advise you on the features, benefits and costs during the Verification Call.

Child's Term Life Rider

Apply Now

Mortgage Disability Rider

Apply Now

Guaranteed Insurability Rider

Apply Now

Disability Waiver of Premium

Apply Now

Liability Disclosure

Based on the answers to the health questions, you may be approved for this coverage. Approval is not guaranteed and will be contingent on the Insurance Company reviewing your application and Medical Information Bureau (MIB). The Insurance Company may also request medical tests with a nurse and/or request your health record from your family doctor or medical clinic on a case-by-case basis.

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