Full Legal Name *

First Name

Last Name

Gender

Male

Female

Phone *

(###)

###

####

Address *

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

Driver's License Issue Date

MM

DD

YYYY

Date of Birth *

MM

DD

YYYY

Address of your family doctor *

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

Landing Date in Canada *

MM

DD

YYYY

Insurances *

Disability Insurance

Critical Insurance

Health & Dental Insurance

Life Insurance

Term Insurance

Super-Visa Insurance

Travel Insurance

Truck Driver - Insurance for traveling in Canada

Truck Driver - Insurance for traveling outside Canada

None of the Above

Investments & Retirement Planning *

Annuities

Segregated Funds

Long Term Care

RRSP

RESP

CPP

None of the Above

Main Beneficiary 1 *

First Name

Last Name

Date of Birth *

MM

DD

YYYY

Main Beneficiary 2

First Name

Last Name

Date of Birth

MM

DD

YYYY

Contingent Beneficiary 1

First Name

Last Name

Date of Birth

MM

DD

YYYY

Contingent Beneficiary 2

First Name

Last Name

Date of Birth

MM

DD

YYYY