| Today's date: |
|
| Name: |
|
| Coverage(s) of interest (check all that apply):
|
Travel Insurance
Visitors to Canada Travel
Medical
Dental
Life
Disability
Long term care
Critical Illness
Group medical
Group Dental
Group Disability
Group Life
|
| Please be specific about what areas you need
coverage for and why (Example: For medical insurance, you may want
chiropractic, massage therapy, or eyeglasses, because these are current
issues): |
|
| How Soon do you require contact?: |
|
| When telephone call required by: Other
|
|
| Preferred method of conversation: |
|
| Date of Birth (required for medical and travel
insurance): |
|
| Smoking Status: |
|
| Spouse's name: |
|
| Date of Birth: Spouse (required for travel or
medical insurance): |
|
| Spouse's Smoking Status: |
|
| Children's name(s) and dates of birth (required
for travel or medical insurance): |
|
| Best Email Address for correspondence:
|
|
| Like to be added to email list?: (Note your
email is not shared with third parties): |
Yes
No
|
| Telephone: Home: |
|
| Telephone: Work: |
|
| Telephone: Cell: |
|
| Occupation Status: |
Employee
Self-Employed
Unemployed
Retired
Student
|
| What is your occupation?: |
|
| Best time of day to call: |
Before 9 AM
9 AM to 12 PM
12 PM to 2 PM
2 PM to 4 PM
4 PM to 6 PM
6 PM to 8 PM
Other
|
| Other time to call: |
|
| Best number to call: |
Home
Work
Cell
Other
|
| Other number: |
|
| Marital Status: |
Single
Couple (common law)
Married, no children
Married, with children
Single mother
Single father
|
| Current Life Insurance: |
None
Term
Whole Life
Universal Life
Uncertain
Group insurance only
Term and group
Whole life and Group
Universal and Group
|
| Amount of life coverage:
|
|
| Last review of life insurance
plans: |
Under one year ago
Between a year and two years
More than two years ago
Not Applicable
|
| Disability Insurance (current):
|
Group plan at work
None
Personal Disability Plan
|
| Have you ever reviewed how much
income you would receive in the event of a disability
with an insurance advisor? : |
Yes
No
|
| Have you ever had a
comprehensive review of all your insurance needs at
one time, including life, disability, and medical and
dental benefits? : |
Yes
No
|
| Are you concerned about
covering living expenses for yourself and your
family if you or your spouse (if applicable) cannot
work? : |
Yes
No
Unsure but open to idea
|
| Travel Insurance:
Departure date : |
|
| Travel Insurance: How
many days travelling? : |
|
| Travel or Medical
Insurance: Pre-exisiting medications or
conditions? : |
Yes, for me
Yes, for my spouse
Yes, for my child(ren)
Yes, for me and my spouse
No, for all applicants
|
| Travel or Medical
Insurance: Specific details on medications, and
medical conditions : |
|
| Additional Information:
|
|
| How did you hear about
us? : |
|
| If referred by someone,
please help us to thank him or her, and provide
their name: |
|
|
|
Craig Ferguson Insurance Services
,since 1991
Integrity
Insurance Planning....'Insure
with Integrity'
....
