Application Form Are you the person insured on the policy?* Yes No What is your name?* First Last What is your e-mail address* What province was your policy issued in?* British Columbia Alberta Saskatchewan Manitoba Ontario Quebec Prince Edward Island Newfoundland and Labrador New Brunswick Nova Scotia Currently, life settlements are only permitted in Quebec. For all other provinces, Quebec included, we can offer a Life Advance. We welcome you to complete the questionnaire to find out if you qualify. What is the date of birth of the person insured?* MM slash DD slash YYYY What is the gender of the person insured? Male Female Does the insured person have any serious life-shortening medical condition(s)?* Yes No Please briefly describe insured person life-shortening health condition(s)*Is there someone else insured on this policy?* Yes No What type of joint policy is it?* Joint last to die Joint first to die What is the date of birth of the other person insured?* MM slash DD slash YYYY Does he/she has any life-shortening condition(s)?* Yes No Please briefly describe his/her life-shortening health condition(s).*What is the death benefit of your policy?*How often are your premiums paid?* Monthly Annually Are your premiums level or changing?* Level Changing What are your annual premium amounts for each of the following yearsPremium for next twelve monthsPremium in 5 years (annual)Premium in 10 years (annual)Premium in 15 years (annual)Premium in 20 years (annual)Enter amount ANNUALLY, multiply monthly premiums by twelve if needed.What is the amount of your premiums?What type of policy do you own?* Whole Life Universal Life Term to 100 Term Life (T-5, T-10, T-20, T-65) Unknown What is the cash surrender value (CSV) of your policyThis is the value of the investments held in the policy.Are there any policy loans outstanding?* Yes No Unknown Amount of policy loans outstanding*