Client Information Form Accomplish Insurance Services endeavours to maintain the highest standards of confidentiality in dealing with client information and adheres to the Personal Information and Electronic Documents Act (“PIPEDA”), a federal privacy law.Step 1 of 425%Client 1 - Profile InformationName* First Last Date of Birth* DD slash MM slash YYYY Phone*Email* Address* Street Address Address Line 2 City AlbertaBritish ColumbiaManitobaNew BrunswickNewfoundland and LabradorNorthwest TerritoriesNova ScotiaNunavutOntarioPrince Edward IslandQuebecSaskatchewanYukon Province Postal Code Occupation*Annual Income*Client 2 - Profile InformationName First Last Date of Birth DD slash MM slash YYYY PhoneEmail Address Street Address Address Line 2 City AlbertaBritish ColumbiaManitobaNew BrunswickNewfoundland and LabradorNorthwest TerritoriesNova ScotiaNunavutOntarioPrince Edward IslandQuebecSaskatchewanYukon Province Postal Code OccupationAnnual IncomeClient 1 - Mortgage & Debt InformationCurrent Mortgage Balance*Current Monthly Mortgage Payment (Bi-Weekly x2)*Other Debt Balance (vehicle, line of credit, credit card)*Are you covered by creditor/lender insurance (life, disability, or critical illness)Please ExplainClient 2 - Mortgage & Debt InformationCurrent Mortgage BalanceCurrent Monthly Mortgage Payment (Bi-Weekly x2)Other Debt Balance (vehicle, line of credit, credit card)Are you covered by creditor/lender insurance (life, disability, or critical illness)Please ExplainClient 1 - Health InformationHeight in Feet & Inches (ft, in)*Weight (pounds)*In the past 12 months have you used nicotine products (including cigars, e-cigarettes, and smoking cessation aids)?If yes please provide detailsDo you have any current health concerns? Any recent or pending testing or consultations with health professionals?If yes, please provide details here:Client 2 - Health InformationHeight in Feet & Inches (ft, in)Weight (pounds)In the past 12 months have you used nicotine products (including cigars, e-cigarettes, and smoking cessation aids)?If yes please provide detailsDo you have any current health concerns? Any recent or pending testing or consultations with health professionals?If yes, please provide details here:Client 1 - Insurance InformationHave you ever had an application for insurance declined or postponed?If yes, please provide detailsDo you currently have any individual insurance (life, disability, critical illness)?If yes, please provide detailsWhat is your monthly budget for insurance planning?*Client 2 - Insurance InformationHave you ever had an application for insurance declined or postponed?If yes, please provide detailsDo you currently have any individual insurance (life, disability, critical illness)?If yes, please provide detailsWhat is your monthly budget for insurance planning?CAPTCHANameThis field is for validation purposes and should be left unchanged.
