Value for Life Quiz - Agent Referral - Canadian Life Settlements

What is your name?*

First Last

What is the insured person's name?*

If you are not allowed to give us this information, please fill this field with your own name.

First Last

What province was the policy issued in?*

Currently only four provinces allow you to sell your insurance policy: Quebec, Nova Scotia, New Brunswick or Saskatchewan. For any other provinces, we welcome you to complete the questionnaire to find out if you would qualify and we will contact you in the future should regulations change.

What is the date of birth of the person insured?*

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?*

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 the policy?*

How often are the premiums paid?*

Monthly
Quarterly
Annually

What is the amount of the premiums?*

Are the premiums level or changing?*

Level
Changing
Unknown

What type of policy does your client own?*

Whole Life
Universal Life
Term to 100
Term Life (T-5, T-10, T-20, T-65)
Unknown

Are there any policy loans outstanding?*

Yes
No
Unknown

Amount of policy loans outstanding*

Step 2: Take the Value for Life Quiz

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