* = Required field Name: Address: City: Province: Postal Code: Phone Number: Email Address: #1Insured's Name: Date of Birth: Calendar Tobacco Use: Select Never Quit < 12 months ago Quit 1-5 years ago Quit > 5 years ago Currently smoke Only cigars/pipe Marijuana use Amount of Insurance: Sex: Select Male Female Health: Select Excellent Good Fair Poor #2Insured's Name: Date of Birth: Calendar Tobacco Use: Select Never Quit < 12 months ago Quit 1-5 years ago Quit > 5 years ago Currently smoke Only cigars/pipe Marijuana use Amount of Insurance: Sex: Select Male Female Health: Select Excellent Good Fair Poor Security code: Enter security code: