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Agency ID: enter  MarioInsurance

Questions for Critical Illness and Life Insurance:

1. Has any application for insurance been rated, declined or modified in any way?

2. In the past 3 years have you: had your driver's license suspended or been convicted of 3 or more moving violations?

3. In the past 3 years have you: engaged in aviation activity other than as a passenger, or other hazardous sports or activities or do you intend to do so in the future?

4. Have you ever had, or been told you had, or received treatment or advice for: abnormal blood pressure, coronary artery disease, elevated cholesterol, chest pain, palpitations or any other disease or disorder of the heart, blood vessels?

5. Have you ever had, or been told you had, or received treatment or advice for: epilepsy, seizures, brain disorder, stroke, transient ischemic attack (TIA), or any other disease or disorder of the nervous system? cardiovascular system?

6. Have you ever had, or been told you had, or received treatment or advice for: anxiety, depression or any emotional, behavioral, mental or nervous disorder?

7. Have you ever had, or been told you had, or received treatment or advice for: any disease or disorder of the stomach, intestines, liver or pancreas?

8. Have you ever had, or been told you had, or received treatment or advice for: cancer, tumour or any other growth or malignancy?

9. Have you ever had, or been told you had, or received treatment or advice for: diabetes; kidney bladder or urinary disorder; prostate disorder; thyroid disorder; anemia, hepatitis or hepatitis-carrier state or any other blood or glandular disorder?

10. Have you ever had, or been told you had, or received treatment or advice for: AIDS (Acquired Immune Deficiency Syndrome), positive HIV test, or any other immunological disorder?

11. Within the past 6 months: Have you consulted your usual medical advisor other than for colds, flu or annual physical examinations?

12. Within the past 10 years have you: used cocaine or other illegal drugs or received treatment or counseling for excess alcohol use or abuse or drug abuse?

13. Other than for minor ailments and minor surgery, in the past 5 years have you: been under observation, had medical or surgical advice or treatment, or been hospitalized for any disease or disorder not mentioned above?

14. Have you ever required hospitalization for: any nose, throat, eyes, ears, lung or any other respiratory disorder?

15. Have any of your first degree relatives (parents and siblings) had a history of heart disease, kidney disease, diabetes, cancer, stroke, Huntington's Chorea, or any hereditary disease prior to reaching their age 60?

16. Have you been resident in Canada for less than 12 months?

Please contact us for assistance.