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Getting life insurance coverage with us couldn’t be easier. We’ve provided you with an online application form that takes only a few minutes to fill out, to get you covered under an insurance plan you can trust.

All you need to apply is:

  • Provide your basic information like date of birth and gender.
  • Select your level of coverage.
  • Provide us with your mailing address.
  • Choose the beneficiary for your policy.
  • Select the payment option that’s most convenient for you.

Finally, we ask that you closely review all the information you have provided us to ensure everything is accurate and completed in full. All the information you submit to us will be included in your insurance contract and is required to be fully complete to issue you the product.

We will use the information you already provided to check for any errors or omissions that might prevent the application from being a success.
We will call you to review your online application and to arrange a simple online screen share appointment with our certified advisors before completing the actual insurance policy application.
We are required to have that online screen appointment in lieu of an actual physical face to face meeting in order to comply with requirements that our advisors actually meet their clients.
We are taking advantage of the internet to meet those requirements and to cut down on unnecessary travel as we try to serve everyone across the country from our centralized location.

Please note that we are fully committed to protecting the information you provide us, and we keep any and all details fully confidential. Please review our privacy policy to learn about our commitment to protecting your personal information.

Insurance application

Fields marked with  * are mandatory

Date of Birth:*

To qualify for non-smoker status you must have not used any tobacco, nicotine substitutes or marijuana in the past 12 months.

About You

Submit your personal information

Please provide us with your personal information. To ensure your policy is processed immediately, ensure all information is accurate and completed in full.

Residential Telephone:*
Business Telephone:
E-mail Address:*
Preferred Language:*

I am a Canadian resident or landed immigrant currently living in Canada

Canadian Resident?:*

Select Your Plan

Choose a plan that best suits your needs and budget.

The benefits available for each option are based on your age, gender and smoking status that you have provided to us.

The Basic Benefit is payable on death occurring after the second anniversary of the policy sign up date.

Prior to the second anniversary of the policy, the Basic Benefit is equal to 100% of paid premiums.

You can also add some extra "Riders" to the Basic Benefit Plan.

The Accidental Death Benefit rider is up to five times the Basic coverage but not above $250,000. This is for death caused by an accident and occurring at any time after the policy effective date and before the insured’s 65th birthday.

The Child Term Benefit rider if you are a parent under 60 years old your child could receive $5,000 or $10,000.

The Hospital Cash Benefit rider can provide $25/day, $50/day or $100/day to offset daily hospital costs if you are under 65 years old.

Please select the coverage level and riders that meet your needs.

Plan Option:

Choose Your Beneficiary:

Please provide the following details of your designated beneficiary, and indicate their relationship to the insured. If no beneficiary is indicated, the beneficiary will be the estate of the insured/owner.

I hereby designate in this application the individual named below as beneficiary to receive any death benefit payable with respect to the coverage applied for. If no beneficiary is designated, benefits will be payable to my Estate.


Choose the most convenient payment method for you

Please select the payment method for your monthly premiums.

To ensure that your application and payments are processed on time, ensure your credit card or banking information is accurate and up to date.

Upon completing this page, you will be asked to review your full application to confirm all the details you have provided.

Preferred method of payment:*
Credit Card Type:
Card Holder Name:
Credit Card Number:
Expiry Date:
By providing my credit card information, I am authorizing Insurance to charge a monthly premium for this insurance product to the credit card account specified.

Canadian Check numbers

Branch Transit Number:
Financial Institution Number:
Account Number:
Name on Cheque:
Funds Withdrawal day of each month:

I wish to have my premiums withdrawn on the this day of each month.

 By providing my bank details, I am authorizing to make monthly withdrawals from the specified account, or any other account that I designate) to pay the premium for this insurance product. This is a personal Pre-Authorized Debit.

Until further notice, I authorize the institution to process these withdrawals as if I had signed them.

I certify that all account information is accurate and that no other signatures are necessary to authorize these withdrawals.

You may cancel this PAD at any time by providing 30 days notice to us. You may obtain a sample cancellation form, or further information on your right to cancel a PAD Agreement, at your financial institution or by visiting

You have certain recourse rights if any debit does not comply with this agreement. For example, you have the right to receive reimbursement for any debit that is not authorized or is not consistent with this PAD Agreement. To obtain more information on your recourse rights, you may contact your financial institution or visit

Review your Application Form

Below is your Application Form as you have completed it. Please take a moment right now to verify that the information you've provided is correct.
Then, type your signature and click on the 'I Agree' button below.
Typing your signature and clicking the 'I Agree' button represents signing the application.

Attention - click here only if:


By typing my name and providing my electronic signature below, I hereby apply for No Medical Life Insurance from
I hereby declare that:

i) the statements contained in this application, are true and complete;

ii) I am between the ages of 18 and 80 years;

iii) I understand that any material misrepresentation, including misstatement of age or smoker status, may render the insurance void by;

iv) I understand that if death occurs with 2 years from the effective date of my insurance that the death benefit is limited to the amount of premiums I have paid and that other exclusions and limitations apply;

v) I understand that insurance will take effect on the date my application is received by once confirmed in an email acknowledgement to me.

The Policy document will follow.
By submitting my application for insurance on this website application platform I designate, as part of the application for insurance, the beneficiary indicated to receive the proceeds of the policy in accordance with the policy provisions.

Privacy Disclosure

The information collected on this application is required for insurance purposes, including but not limited to processing your application for insurance and for administering the insurance and investigating and processing claims. Further details about the privacy practices of are set out in its Privacy Policy. By submitting this application you agree to the terms of the Privacy Policy. and its affiliates may use the information collected in this application for insurance for the optional purpose of contacting you about other products and services that may be of interest to you. You may elect not to be contacted for marketing purposes at any time. Consult the Privacy Policy.

I consent to sharing my personal information with

I give my Consent:*

Your Signature

Please type your full name and select "I agree" below. Typing your name and clicking the "I agree" button is completion and submission of the application.

Your Signature:*
For added security, please enter:*