General Information MonthJanuaryFebruaryMarchAprilMayJuneJulyAugustSeptemberOctoberNovemberDecember Date12345678910111213141516171819202122232425262728293031 Year194119421943194419451946194719481950195119521953195419551956195719581959196019611962196319641965196619671968196919701971197219731974197519761977197819791980198119821983198419851986198719881989199019911992199419951996199719981999200020012002200320042005200620072008200920102011201220132014201520162017 GenderMaleFemale Smoking StatusSmokerNon-Smoker Type of insurance quote that you are interested: (Check all that apply) Life InsuranceCritical Illness InsuranceDisability Income InsuranceLong Term Care Insurance Select Coverage Plan TypeTerm 10Term 20Term 30Term to age 65Term 100Whole Life / Life PayWhole Life / 20 PayWhole Life / 15 PayWhole Life / 10 Pay Select Coverage Amount$25,000$50,000$75,000$100,000$125,000$150,000$200,000$225,000$250,000$275,000$300,000$325,000$350,000$400,000$425,000$450,000$500,000$550,000$600,000$650,000$700,000$750,000$800,000$850,000$900,000$950,000$1,000,000$2,000,000$3,000,000$4,000,000$5,000,000$6,000,000$7,000,000$8,000,000$9,000,000$10,000,000 Select Coverage Plan TypeTerm 10Term 20Term to age 75Term to age 100Term to age 100 Payable in 20 yearsTerm to age 100 Payable in 15 yearsTerm to age 100 Payable in 10 years Select Coverage Amount$25,000$50,000$75,000$100,000$150,000$200,000$250,000$300,000$350,000$400,000$450,000$500,000 Select Monthly Benefit Amount$1,000$1,500$2,000$2,500$3,000$3,500$4,000$5,000$5,500$6,000$6,500$7,000$7,500$8,000$8,500$9,000$9,500$10,000$10,500$11,000$11,500$12,000$12,500$13,000$13,500$14,000$14,500$15,000$14,500$15,000$15,500$16,000$16,500$17,000$17,500$18,000$18,500$19,000$19,500$20,000$20,500$21,000$21,500$22,000$22,500$23,000$23,500$24,000$24,500$25,000 Select Monthly Benefit Period2 Years5 YearsTo Age 65To Age 70 Select Waiting Period30 Days60 Days90 Days120 Days180 Days365 Days720 Days Select Monthly Benefit Amount$1,000$1,500$2,000$2,500$3,000$3,500$4,000$5,000 Select Monthly Benefit Period2 Years5 YearsLifetime Select Waiting Period30 Days90 Days180 Days Group Benefits Quotation From (Download) Group Benefits Request for Quotation From-PDF-fillable version Personal Information Select ProvinceAlbertaBritish ColumbiaNova ScotiaManitobaNew BrunswickNewfoundland and LabradorNorthwest TerritoriesNunavutOntarioPrince Edward IslandQuebecSaskatchewanYukon Any notes or comments to help us prepare for your quote?