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Personal Information

Date of Birth:	01020304050607080910111213141516171819202122232425262728293031 JanuaryFebruaryMarchAprilMayJuneJulyAugustSeptemberOctoberNovemberDecember 1930193119321933193419351936193719381939194019411942194319441945194619471948194919501951195219531954195519561957 19581959196019611962196319641965196619671968196919701971197219731974197519761977197819791980198119821983198419851986 19871988198919901991199219931994199519961997199819992000
Sex:	Male Female
Smoker Status:	Smoking Non-Smoking
Are you eligible for Employment Insurance?	Yes No

Elimination Period:

30 days 90 days

Desired Coverage

	Monthly Benefit:	$800$900$1000$1100$1200$1300$1400$1500$1600$1700$1800$1900$2000$2100$2200$2300$2400$2500$2600$2700$2800$2900$3000$3100$3200$3300$3400$3500$3600$3700$3800$3900$4000$4100$4200$4300$4400$4500$4600$4700$4800$4900$5000$5100$5200$5300$5400$5500$5600$5700$5800$5900$6000$6100$6200$6300$6400$6500$6600$6700$6800$6900$7000$7100$7200$7300$7400$7500$7600$7700$7800$7900$8000
	Cost of Living Indexation Rider:	Yes No
	Guaranteed Future Insurability Rider:	Yes No	$
	Retirement Benefit Rider:	Yes No	$

Complementary coverage (From $10,000 to $250,000 by multiple of $1,000)

Lump-sum payment in the event of Critical Illness:

Yes No

$