Andrej Kopac

Birthday

Sex assigned at birth*

Marital Status?*

Do you have any dependents under the age of 18?*

Have you used tobacco products in the past 3 years?*

Have you used cannabis products in the past 3 years (more than 3 times per week)?*

Employment level?*

Existing life insurance amount? *

Do you own a home?*

Balance owing on existing mortgages? *

What is your total debt (not including mortgages)? *

What is the value of any additional property you might own (cottage, income unit ...)?*

Do you have any current or a history of any significant medical conditions? (diabetes, heart problems, high blood pressure, serious mental health issue requiring treatment or similar) Either diagnosed or under medication?*

Have you ever been Declined, Rated or offered Modified Coverage when applying for Life Insurance?*

Have you ever been charged with careless or reckless driving?*

Have you had more than 5 motor vehicle tickets for moving violations in the past 10 years (not including parking tickets)?*

Have you ever been charged with or convicted of a criminal offence?*

Have you declared bankruptcy or had other significant financial problems in the past 7 years?*