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* 1. First & Last Name

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* 2. Date of birth

Date

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* 3. Gender

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* 4. City and Province you live in?

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* 5. Phone number

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* 6. Email

The following questions will help us identify who much insurance you'd like to purchase, so we can run the quote accordingly.

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* 7. Estimated Estate Value (real estate, cash, investments...)

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* 8. How much would you like to pay your executor (any number between $5K and $44K)?

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* 9. How many executor(s) have you named in your will?

The following two questions are required to confirm which rate you can qualify for.
This information will NOT be shared with a third party and will remain STRICTLY CONFIDENTIAL. 

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* 10. Medical question that will confirm what rate you can qualify for: 
Are you currently confined to a hospital or nursing home, or have you ever been diagnosed as having a terminal Illness, Alzheimer’s Disease, tested HIV positive or advised that you have AIDS-related conditions?

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* 11. Second medical question: 
During the past five (5) years, have you ever been treated for, or been diagnosed as having:
a. Disease or disorder of the heart, circulatory or vascular systems, stroke or any cancer?
b. Disease or disorder of the lungs, liver or kidney; alcoholism or drug abuse?
c. Brain disorder or tumor, seizure, paralysis, psychosis, lupus or multiple sclerosis?
d. Blood disease or disorder, or both high blood pressure and diabetes together?

Thank you for completing these questions, we will get back to you shortly with a quote and will send you some information about the coverage.

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