Request Information

Online Life Insurance Quote Form

This form can be used to receive a quote for mortgage insurance or other types of life insurance. This is not an automatic request form. You will receive the quotation with 1-2 business days depending on your request. You may choose to receive this information via e-mail, by facsimile or regular mail. This service is available to residents of Ontario only.

Your Contact Details

Full Name:	* required
Street Address:	* may be a required field
Address (Cont.):
City:	* required
Province:	* required
Postal Code:	* may be a required field
Country:
Work Phone:
Home Phone:	* may be required field
Fax:	* may be required field
E-Mail:	* required field

Are you presently a client of Reeves Financial Services? Yes No

Please answer each of the following questions:

1. Have you any intention of replacing or changing any existing insurance?
Yes No

2. Indicate if you use or have used any of the following nicotine products as well as the date last used:

a) Cigarettes, Cigarillos, Nicotine Patches, Nicotine Gum, Marijuana
Yes No If yes, please indicate date last used
b) Cigars (any type), Pipe, Chewing Tobacco
Yes No If yes, please indicate date last used

3. Have you ever had an application for life, health, Critical Illness or disability insurance, reinstatement or change either: rated, declined, postponed, modified or not proceeded with?
Yes No

4. Have you within the past 90 days, other than for normal childbirth, been admitted or advised to be admitted to a hospital or other medical facility or had any surgery performed or recommended?
Yes No

5. Have you in the past 5 years ever had, been told you may have or been advised to have tests for: cancer, drug or alcohol abuse, heart or circulation problems such as stroke, high blood pressure, chest pain, unexplained infections, or have you ever had, been told you may have, been advised to have tests for or received information indicating possible exposure to AIDS (HIV)?
Yes No

6. Please indicate your gender:
Female Male

7. Please indicate your month and year of birth:
Month: Year:

Additional Questions? I have questions concerning the quotation: (please indicate them to us below)

How would you like to receive your quotation? (check all that apply) E-mail Fax Regular Mail

Please read the following information carefully and indicate that you have read and understood the following disclaimer:

This form is not intended to solicit the replacement of insurance already in force. I do not construe the information on this web-site as providing individual financial or insurance advice. I will not take any steps concerning mortgage or life insurance coverage without first consulting a qualified advisor. I understand that individual policies for mortgage insurance come with certain restrictions, for example, coverage will be void if the life insured commits suicide within two years of the application being approved and issued. I need to fully understand all these restrictions. I further understand that the provision of a quotation by Reeves Financial Services Inc. does not guarantee that I will be able to have a policy issued for me by an insurance company.

I have read and understood the above statement.

Please be sure you provide us with the necessary information above so that we may deliver to you the quotation in the manner you wish to receive it in.

Would you like to refer this site to a friend? Please send my friend information about this site!

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