Do you have any Life, Critical Illness, or Disability Insurance in force or pending, including with RBC?
4
Beneficiaries
Primary Beneficiary
Primary 1
Contingent Beneficiary
Contingent 1
5
Financial Information
Are you currently employed?
Do you work in any of the following: blaster/explosives, bridge construction, diplomat, foreign aid/journalism, logging, marijuana, military, offshore oil, professional diving, steeplejack, structural steel/iron, underground mining?
Do you have an outstanding mortgage?
Do you have income from other sources?
Is all other income from rent, interest, dividends, investments, maternity leave, child support, alimony, pension, student loan, scholarship or grant?
Have you within the past 5 years declared personal or corporate bankruptcy?
6
Health Questions (TIA)
1. Have you ever been treated for or had any indication of heart or circulatory disease, heart attack, high blood pressure, chest pain, abnormal ECG, stroke, TIA, diabetes, chronic kidney/liver/lung disease, cancer, tumour, MS, paralysis, motor neuron disease, Alzheimer's, Huntington's, Parkinson's, AIDS/ARC/HIV, loss of speech, blindness or deafness?
2. Within the past year, other than normal childbirth, been admitted to hospital or advised to do so?
3. Been advised to have any tests, investigations, or surgery not yet done?
4. In the past year had any application for life insurance declined, rated or modified?
5. Aware of any symptoms for which you have not sought treatment or for which treatment is planned or pending?
7
Banking Information
8
Insurance History
Do you have any other insurance applications pending?
Have you ever been declined for insurance?
Have you ever had your life insurance, critical illness, or disability rated or modified?
Do you have any in-force insurance on your life, excluding group or credit insurance?
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