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| Client Name |
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| Client Phone |
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| Client Email |
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| Age |
Last
Nearest
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| Birth Date |
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| Gender |
Male
Female
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| Tobacco use (Ever?) |
Yes
No
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| Province |
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| Face Amount |
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| Premium Payment |
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| Product Type |
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Select the Critical Illnesses that need to be covered by the quoted products:
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| Underwriting Risk |
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Please Note: Comparisons and quotes are intended for guidance and educational purposes only. The consumer is urged to seek the advice of independent life insurance advisors. E.&.O.E.
WinQuote® is a registered trademark of CompuOffice Software Inc.
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