Term Life Insurance Application

Coverage Selected

Face AmountMin: 100,000 Max: 2,000,000

Plan Type

Beneficiary

Beneficiary First Name

Beneficiary Middle Initial

Beneficiary Last Name

Relationship to the Insured

Existing Coverage

Do you have any other life insurance coverage with this or other companies?

Yes

Company

Issue Year

Amount

Does the policy being applied for involve REPLACEMENT of insurance with this or any other company?

Note: Answer 'No' if you are replacing your bank owned mortgage life insurance. Only answer 'Yes' if you are replacing a life insurance policy that you own yourself.

Yes

*Never cancel or modify existing life insurance coverage until your new policy is fully in force

Company Name

Policy Number

Type of Life Insurance

Medical History Call

Contact the Insured

Home Phone

Cell Phone

Best Time to Contact

9AM - Noon

Noon - 4PM

4PM - 8PM

Time Zone

Policies are underwritten by Wawanesa Life Insurance, a Canadian life insurance company rated A Excellent.

The Term Guy is a licensed life insurance agency serving residents of Ontario (Lic #37992M), British Columbia (Lic. #LIC-2021-0030559-R02), and Alberta (Lic. #5-11247944-2021).

Term Life Insurance Application

Life Insured

Coverage Selected

Beneficiary

Existing Coverage

Medical History Call