To obtain a quote, please complete as much of the following short questionnaire as you can. The more information you provide, the more accurate our quote will be. We aim to respond to your request within 48 hours. Please choose a product. For multiple products, please repeat the process.ProductsChoose OptionLloyd's DILloyd's GIDCareer Transition DisabilityPilot Loss of LicenceContingent Contract ProtectionPersonal AccidentKidnap & Ransom (Special Contingency)Note: Coverage is only available to pilots who have a Canadian address.Advisor Information:Name Firm (optional) Phone #* Email* Client Information:Initials or other non-identifying description Province*ABBCMBNBNLNSNTNUONPEQCSKYTDate of Birth (DD/MM/YYYY)* DD slash MM slash YYYY Date of Birth (DD/MM/YYYY) *Issue ages 25-60 DD slash MM slash YYYY Job Title* Final Annual Base Salary* Last Day Worked (or expected last day worked) MM slash DD slash YYYY Severance Period (or expected severance period) Any Significant Health or Lifestyle (alcohol, drugs) issues that may affect eligibility for coverageGender Male Female Smoking Status Smoker Non Smoker If a former smoker, please provide date of cessation: Month Year Income Occupation BuildHeight Weight Coverage is for Personal Need Business Need Type of Business Insurance required? Buy Sell Loan Coverage Business Overhead Expense Personal Needs OptionsIncome replacementOtherPersonal Needs Other Business Need OptionsBuy/Sell Funding or Share RepurchaseBusiness or Professional Overhead ExpenseLoan ProtectionOtherBusiness Need Other Amount of in force DI/LTD coverage In force coverage is Taxable Non-taxable Is the proposed insured covered by Worker’s Comp? Yes No Benefit Amount Requested Monthly Lump Sum Monthly Benefit Amount Requested Monthly Elimination Period30 days60 days90 days120 daysOtherMonthly Elimination Period Other Monthly Benefit Period12 months24 months36 months48 months60 monthsMonthly Benefit Amount Lump Sum Benefit Elimination Period12 months24 months36 months48 months60 monthsOtherLump Sum Elimination Period Other Lum Sum Benefit Amount Benefits will be Taxable Non-taxable Last day worked Face amount required Face amount required (Min $300K - Max $10M) Coverage is for Personal Need Business Need Is this replacing an in force policy? Yes No Face amount of current policy Premium of current policy Type of Business Insurance required? Key Person Buy Sell Loan Coverage Business Need OptionsKey PersonBuy/Sell Funding or Share RepurchaseLoan ProtectionOtherBusiness Need Other Total other Life Insurance in force or pending Hazard required 24 hr coverage avocation risk only If avocation risk only selected, provide details:Does your client travel outside Canada? Yes No Country of residence Locations of travel outside Canada including city and country Average duration of each trip Number of trips taken per year If travel is for occupation, please provide work rotation if appropriate, e.g. 28 days in, 28 days out Please list all forms of travel e.g. type of ground transportation and air travel such as commercial airlines, non-scheduled aircraft, helicopter exposure etc. Any other unusual exposures Amount of in force Loss of Licence Insurance Coverage and Benefit Amount Required Temporary Loss of Licence Monthly Permanent Loss of Licence Lump Sum Temporary Loss Monthly Amount Permanent Loss Lump Sum Amount Total other Disability Insurance in force or pending Type of commercial aircraft flown Fixed wing Rotary wing Both Employer if known Choose one of the following options Individual or Family Coverage Corporate Coverage Company name Location of Head Office Nature of Business Website Number of Directors Officers Employees Total Sales Net Assets Location of all overseas operations, including nature of operation and approximate number of employees per each location Location of travel outside Europe, Canada & the USA including locations, durations, purpose of travel and special security measures that are taken in high risk locations Have there been any incidents which would have given rise to a claim under the policy? Yes No If yes, please give details Coverage limit requested: (Note: Limit cannot exceed corporate net assets)Option 1 Option 2 Option 3 Name Occupation Date of Birth Country of Residence Personal Net Assets meet or exceed (choose one) CDN $250,000 CDN $500,000 CDN $1,000,000 CDN $2,000,000 CDN $3,000,000 CDN $5,000,000 CDN $10,000,000 CDN $15,000,000 Please list the name, age, relationship and city of residence of the individuals to be insured. Special security measures that are taken in high risk locations.Have there been any incidents which would have given rise to a claim under the policy? Yes No If yes, please give details Quote coverage limits of: (Note: Limit cannot exceed personal net assets)Option 1 Option 2 Option 3 Name of Employer or Sponsor Organization Purpose of Coverage Income Replacement Other Provide detailsTotal Number of Employees or Group Members Number of Employees or Group Members requiring GSI DI coverage Maximum Monthly Benefit being requested Benefit Formula In force coverage Maximum Benefit Current Insurer if applicable Will in force coverage be replaced? Yes No Please provide 5 year loss history below or email to info@hunmcc.comIs coverage Taxable Non-Taxable Policy Ownership Corporate Individual Any other pertinent information you would like to sharePlease send an MS Excel census file census info@hunmcc.com including the following: Occupation or title of proposed insured persons Age or date of birth Annual income Bonus if applicable Amount of in force coverage and insurer Does your client have any of the following impairments? Medical history Lifestyle history Foreign travel, residency, or citizenship Does your client have any of the following impairments? Medical History Lifestyle History HiddenDoes your client have any of the following impairments? Foreign travel, residency, or citizenship Medical or Lifestyle Impairment 1Nature of Impairment or specific diagnosisMonth Year Approximate date of diagnosis:Treatment Current Symptoms Medical or Lifestyle Impairment 2Nature of Impairment or specific diagnosisApproximate date of diagnosis:Month Year Treatment Current Symptoms Medical or Lifestyle Impairment 3Nature of Impairment or specific diagnosisApproximate date of diagnosis:Month Year Treatment Current Symptoms If the client has significant foreign travel exposure, residency or citizenship please provide detailsCountry of residence Locations of travel outside Canada including city and country Average duration of each trip Number of trips taken per year If travel is for occupation, please provide work rotation if appropriate, e.g. 28 days in, 28 days out Please list all forms of travel e.g. type of ground transportation and air travel such as commercial airlines, non-scheduled aircraft, helicopter exposure etc HiddenIf the client has financial underwriting challenges, please provide detailsOther impairments HiddenAre there any other important details we should know about this individual?Was your client declined by the traditional insurance market? Yes No Approximate date of declineMonth Year Declined policy number: Declining company? How did you hear about Hunter McCorquodale? I have an existing relationship with Hunter McCorquodale Referred by another advisor Referred by my MGA/National Account Received an email broadcast from Hunter McCorquodale Saw your booth at a trade show Google search for product IBMCO Other Name of referring advisor Name of National Account of MGA Name of Trade Show event and date Other Would you like to be added to our mailing list? Yes No
