Birth Date Jan Feb Mar Apr May Jun Jul Aug Sep Oct Nov Dec 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 Gender Male Female Ever used tobacco or related substances? Yes No   Cigarette Never last 12 months More than 1 yr More than 2 yrs More than 3 yrs More than 4 yrs More than 5 yrs More than 6 yrs More than 10 yrs More than 15 yrs More than 25 yrs Cigar Never last 12 months More than 1 yr More than 2 yrs More than 3 yrs More than 4 yrs More than 5 yrs More than 6 yrs More than 10 yrs More than 15 yrs More than 25 yrs Pipe Never last 12 months More than 1 yr More than 2 yrs More than 3 yrs More than 4 yrs More than 5 yrs More than 6 yrs More than 10 yrs More than 15 yrs More than 25 yrs Snuff Never last 12 months More than 1 yr More than 2 yrs More than 3 yrs More than 4 yrs More than 5 yrs More than 6 yrs More than 10 yrs More than 15 yrs More than 25 yrs Cigarello Never last 12 months More than 1 yr More than 2 yrs More than 3 yrs More than 4 yrs More than 5 yrs More than 6 yrs More than 10 yrs More than 15 yrs More than 25 yrs Chew Never last 12 months More than 1 yr More than 2 yrs More than 3 yrs More than 4 yrs More than 5 yrs More than 6 yrs More than 10 yrs More than 15 yrs More than 25 yrs Marijuana Never last 12 months More than 1 yr More than 2 yrs More than 3 yrs More than 4 yrs More than 5 yrs More than 6 yrs More than 10 yrs More than 15 yrs More than 25 yrs Prescribed Never last 12 months More than 1 yr More than 2 yrs More than 3 yrs More than 4 yrs More than 5 yrs More than 6 yrs More than 10 yrs More than 15 yrs More than 25 yrs Province Face Amount Face Amount $ 25,000 $ 30,000 $ 35,000 $ 40,000 $ 45,000 $ 50,000 $ 55,000 $ 60,000 $ 65,000 $ 70,000 $ 75,000 $ 80,000 $ 85,000 $ 90,000 $ 95,000 $ 100,000 $ 125,000 $ 150,000 $ 175,000 $ 200,000 $ 225,000 $ 250,000 $ 275,000 $ 300,000 $ 325,000 $ 350,000 $ 375,000 $ 400,000 $ 425,000 $ 450,000 $ 475,000 $ 500,000 $ 550,000 $ 600,000 $ 650,000 $ 700,000 $ 750,000 $ 800,000 $ 850,000 $ 900,000 $ 950,000 $1,000,000 $1,250,000 $1,500,000 $1,750,000 $2,000,000 $2,250,000 $2,500,000 $2,750,000 $3,000,000 $3,500,000 $4,000,000 $4,500,000 $5,000,000 $6,000,000 $7,000,000 $8,000,000 $9,000,000 $10,000,000 $11,000,000 $12,000,000 $13,000,000 $14,000,000 $15,000,000 $16,000,000 $17,000,000 $18,000,000 $19,000,000 $20,000,000 $21,000,000 $22,000,000 $23,000,000 $24,000,000 $25,000,000 $26,000,000 $27,000,000 $28,000,000 $29,000,000 $30,000,000 Premium mode Annual Semi-Annual Quarterly Monthly Product Type Health Risk Super Preferred Preferred Select Regular Regular Physique   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 trademark of CompuOffice Software Inc.