Life Insurance

Will your loved ones be taken care of if something happens to you? Contact us today to find out how you can ensure your family is covered if the unthinkable happens.

Get a Life Quote Online

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Personal Information

First Name	Last Name

Date of Birth	Occupation

Address	Email

My Health Is:

Do you have a spouse? YesNo

Spouse First Name	Spouse Last Name

Spouse Date of Birth	Spouse Occupation

My Spouse's Health Is:

Home Phone (required)	Mobile Phone (required)	Preferred Contact Method
		Home PhoneCell PhoneEmail

Combined Household Income	Between $25K-$45KBetween $50K-$85KOver $100K

Dependent Information

Do you have any dependents? YesNo

People Financially Dependent on you.

Children

Do you have any children? YesNo

Number of Children

If not now, are you planning to have children in the next 5 years?	YesNo

Smoker/Non-Smoker	Height	Weight
SmokerNon-Smoker

Are you currently taking any medication? YesNo

If yes, please list your medications.

Do you have a family doctor? YesNo

If yes, enter your doctor's name.

When was your last visit to your GP?

Do you currently have life insurance? YesNo

If yes, how much coverage?

Do you currently have critical illness coverage? YesNo

If yes, how much coverage?

Do you currently have disability coverage? YesNo

If yes, what is your monthly benefit?

Do you plan to travel outside North America in the next 12 months? YesNo

If yes, where will you be traveling?

Reach Us

Contact us today for a FREE quote.

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163 Ormond Streeet,
Brockville, ON K6V 2L2

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Tel: 613-342-9076
Toll Free: 866-648-7889

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contact@rickbeer.ca

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