Important:
- If you should print the following forms, please make sure of its quality and take into account the number of copies required, when applicable.
- To access the French version of the forms, select "Français" on the upper right hand side of your screen.
- All provinces except Quebec
- Quebec
All provinces except Quebec
Accident, injury or illness questionnaire - 10425E01 (10-12)
1 page - 65 kb
Alcohol Consumption and/or Drug use Questionnaire - 03221E01 (10-12)
1 page - 64 kb
Anxiety, Emotional or Stress Disorder Questionnaire - 10437E01 (10-12)
1 page - 101 kb
Application Memorandum - 05167E (05-12)
1 page - 33 kb
Authorization to collect and disclose personal information to a third party -
17008A01 (10-12)
1 page - 73 kb
Authorization to disclose medical information to the attending physician - 11166E (11-06)
1 page - 68 kb
Aviation and sports flying questionnaire - 10409E01 (10-12)
1 page - 79 kb
Back pain questionnaire - 10426E01 (10-12)
1 page - 98 kb
Business Financial Questionnaire (to be completed for all applications of $1,250,000 and over (including in-force insurance) life or critical illness) - 03053E01 (10-12)
1 page - 37 kb
Cardiovascular Recheck - 3793L (02-01)
1 page - 49 kb
Detailed Examination - 05079E (07-04) - to be completed with form 15369A
1 page - 68 kb
Diabetes questionnaire - Attending physician - 10424E01 (10-12)
2 pages - 99 kb
Diabetes questionnaire - Life insured - 10423E01 (10-12)
1 page - 60 kb
Digestive trouble questionnaire - 10427E01 (10-12)
1 page - 93 kb
Driving history questionnaire - 10429E01 (10-12)
1 page - 86 kb
Epilepsy Questionnaire - 03230E01 (10-12)
1 page - 66 kb
Financial Supplement - 00211E (04-01)
1 page - 33 kb
Foreign Language Declaration
Chinese - 11010E01 (11-01)
1 page - 131 kb
Farsi (Arab) - 11012E01 (11-01)
1 page - 80 kb
Italian - 11013E01 (11-01)
1 page - 24 kb
Laotian - 11014E01 (11-01)
1 page - 36 kb
Polish - 11015E01 (11-01)
1 page - 86 kb
Portuguese - 11020E01 (11-01)
1 page - 48 kb
Punjabi-pun - 11018E01 (11-01)
1 page - 36 kb
Russian - 12121E01 (12-05)
1 page - 103 kb
Spanish - 11011E01 (11-01)
1 page - 24 kb
Tamil - 11016E01 (11-01)
1 page - 104 kb
Turkish - 11017E01 (11-01)
1 page - 124 kb
Vietnamese - 11019E01 (11-01)
1 page - 83 kb
Foreign Residence/Travel Questionnaire - 03261E01 (10-12)
1 page - 58 kb
Medical authorization - 10430E01 (10-12)
1 page - 54 kb
Motor racing questionnaire - 10408E01 (10-12)
1 page - 74 kb
Personal Financial Questionnaire (to be completed for all applications of $1,250,000 and over (including in-force insurance) life or critical illness) - 03052E (05-07)
1 page - 36 kb
Pulmonary and Bronchial Diseases Additionnal Questionnaire - 1700901A (10-12)
1 page - 63 kb
Questionnaire regarding a person injured in an accident - 10438E01 (10-12)
1 page - 103 kb
Scuba diving, rock climbing and mountaineering questionnaire - 10407E01 (10-12)
1 page - 77 kb
Tobacco use questionnaire - 10436E01 (10-12)
1 page - 87 kb
Quebec
Accident, injury or illness questionnaire - 10425E (10-12)
1 page - 66 kb
Alcohol Consumption and/or Drug use Questionnaire - 03221E (11-01)
1 page - 63 kb
Anxiety or emotional/stress disorder questionnaire - 10437E (10-12)
1 page - 101 kb
Authorization for the disclosure of a driving record by the SAAQ - through and Intermediary - (HOOPER) - 5981A-55 (12-01)
1 page - 144 kb
Authorization for the disclosure of a driving record by the SAAQ (KEYFACTS) - 5981A 75 (08-04)
1 page - 26 kb
Authorization to collect and disclose personal information to a third party -
17008A (10-12)
1 page - 74 kb
Authorization to disclose medical information to the attending physician - 00103E06 (11-06)
1 page - 68 kb
Aviation and Sports Flying Questionnaire - 10409E (10-12)
1 page - 117 kb
Back pain questionnaire - 10426E (10-12)
1 page - 97 kb
Business Financial Questionnaire (to be completed for all applications of $1,250,000 and over (including in-force insurance) life or critical illness) - 03053E (10-12)
1 page - 37 kb
Cardiovascular Recheck - 3793L (02-01)
1 page - 49 kb
Detailed Examination - 05079E (07-04) - to be completed with form 15369A
1 page - 68 kb
Diabetes questionnaire / Attending physician - 10426E (10-12)
1 page - 97 kb
Diabetes questionnaire / Life insured - 10423E (10-12)
1 page - 58 kb
Digestive trouble questionnaire - 10427E (10-12)
1 page - 93 kb
Disability Benefit Questionnaire - 05053E (06-05)
1 page - 38 kb
Driving history questionnaire - 10429E (10-12)
1 page - 86 kb
Epilepsy Questionnaire - 03230E (11-01)
1 page - 67 kb
Financial Supplement - 00211E (02-04)
1 page - 38 kb
Foreign Language Declaration
Chinese - 11010E (11-01)
1 page - 131 kb
Farsi (Arab) - 11012E (11-01)
1 page - 80 kb
Italian - 11013E (11-01)
1 page - 24 kb
Laotian - 11014E (11-01)
1 page - 36 kb
Polish - 11015E (11-01)
1 page - 98 kb
Portuguese - 11020E (11-01)
1 page - 26 kb
Punjabi-pun - 11018E (11-01)
1 page - 36 kb
Russian - 12121E (12-05)
1page - 103 kb
Spanish - 11011E (11-01)
1 page - 24 kb
Tamil - 11016E (11-01)
1 page - 104 kb
Turkish - 11017E (11-01)
1 page - 101 kb
Vietnamese - 11019E (11-01)
1 page - 83 kb
Foreign Residence/Travel Questionnaire - 03261E (10-12)
1 page - 58 kb
Medical authorization - 10430E (10-12)
1 page - 54 kb
Motor Racing Questionnaire - 10408E (10-12)
1 page - 73 kb
Personal Financial Questionnaire (to be completed for all applications of $1,250,000 and over (including in-force insurance) life or critical illness) - 03052E (05-07)
1 page - 36 kb
Pulmonary and Bronchial Diseases Additional Questionnaire - 17009A (10-12)
1 page - 62 kb
Questionnaire regarding a person injured in an accident - 10438E (10-12)
1 page - 103 kb
Scuba diving, Rock climbing and Mountaineering Questionnaire - 10407E (10-12)
1 page - 76 kb
Tobacco use questionnaire - 10436E (10-12)
1 page - 85 kb