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Obtain a customized mortgage protection life insurance quote using the form below

Date of Birth:	Jan Feb Mar Apr May Jun Jul Aug Sep Oct Nov Dec 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31
Gender:	Male Female
Have you used any tobacco products in the last 12 months?	Yes No
Cigarette Never last 12 months More than 1 yr More than 2 yrs More than 3 yrs More than 4 yrs More than 5 yrs More than 6 yrs More than 10 yrs More than 15 yrs More than 25 yrs Cigar Never last 12 months More than 1 yr More than 2 yrs More than 3 yrs More than 4 yrs More than 5 yrs More than 6 yrs More than 10 yrs More than 15 yrs More than 25 yrs Pipe Never last 12 months More than 1 yr More than 2 yrs More than 3 yrs More than 4 yrs More than 5 yrs More than 6 yrs More than 10 yrs More than 15 yrs More than 25 yrs Snuff Never last 12 months More than 1 yr More than 2 yrs More than 3 yrs More than 4 yrs More than 5 yrs More than 6 yrs More than 10 yrs More than 15 yrs More than 25 yrs Cigarello Never last 12 months More than 1 yr More than 2 yrs More than 3 yrs More than 4 yrs More than 5 yrs More than 6 yrs More than 10 yrs More than 15 yrs More than 25 yrs Chew Never last 12 months More than 1 yr More than 2 yrs More than 3 yrs More than 4 yrs More than 5 yrs More than 6 yrs More than 10 yrs More than 15 yrs More than 25 yrs Marijuana Never last 12 months More than 1 yr More than 2 yrs More than 3 yrs More than 4 yrs More than 5 yrs More than 6 yrs More than 10 yrs More than 15 yrs More than 25 yrs Prescribed Never last 12 months More than 1 yr More than 2 yrs More than 3 yrs More than 4 yrs More than 5 yrs More than 6 yrs More than 10 yrs More than 15 yrs More than 25 yrs
Province:	Provinces
Face Amount:	$ 25,000 $ 30,000 $ 35,000 $ 40,000 $ 45,000 $ 50,000 $ 55,000 $ 60,000 $ 65,000 $ 70,000 $ 75,000 $ 80,000 $ 85,000 $ 90,000 $ 95,000 $ 100,000 $ 125,000 $ 150,000 $ 175,000 $ 200,000 $ 225,000 $ 250,000 $ 275,000 $ 300,000 $ 325,000 $ 350,000 $ 375,000 $ 400,000 $ 425,000 $ 450,000 $ 475,000 $ 500,000 $ 550,000 $ 600,000 $ 650,000 $ 700,000 $ 750,000 $ 800,000 $ 850,000 $ 900,000 $ 950,000 $1,000,000 $1,250,000 $1,500,000 $1,750,000 $2,000,000 $2,250,000 $2,500,000 $2,750,000 $3,000,000 $3,500,000 $4,000,000 $4,500,000 $5,000,000 $6,000,000 $7,000,000 $8,000,000 $9,000,000 $10,000,000 $11,000,000 $12,000,000 $13,000,000 $14,000,000 $15,000,000 $16,000,000 $17,000,000 $18,000,000 $19,000,000 $20,000,000 $21,000,000 $22,000,000 $23,000,000 $24,000,000 $25,000,000 $26,000,000 $27,000,000 $28,000,000 $29,000,000 $30,000,000
Premium Mode:	Annual Semi-Annual Quarterly Monthly
Product Type
Please Note: Comparisons and quotes are intended for guidance and educational purposes only. The consumer is urged to seek the advice of independent life insurance advisors. E.&.O.E. WinQuote™ is a trademark of CompuOffice Software Inc.
I understand that my Mortgage Broker receives remuneration for performing their administrative duties. I have received the LCPP brochure. I authorize and Instruct my Mortgage Broker to provide to the Insurer all my Mortgage Information, using the Approved System, and my Submitted Application which forms a part of any insurance contract issued. My premiums and coverage may differ from the amounts shown, based on the final Mortgage Information provided. Submitted Application means this completed form or a copy (which is as valid as the original). I authorize any person to provide the Insurer with my medical information. I acknowledge the need for this information for the purposes shown in the brochure. I hereby apply for Insurance (except coverages waived above) or such alternative coverage as may be available under the Link Canada Protection Plan, subject to the terms and conditions of any Certificate of Insurance issued to me. If ineligible, I have initiated to waive above to acknowledge my ineligibility.