BMO
Insurance
Application
Form

Please fill out the form to
Apply for BMO Insurance.

* Required

Step 1

Okay, before we get started, we just have a few questions to confirm that you qualify for this type of insurance.
Note: For each ‘Single Life’ coverage, please complete and submit a separate application.

The rates quoted are based on the inputs provided and may be subject to change.

We use the information in this application to determine whether or not you are eligible for the coverage and to establish the premium rates for the coverage you are applying for. If you misrepresent any facts or the information you provide is not current, correct and complete, we can cancel any policy we have issued on the basis of the information you provided.

We respect your privacy and are committed to keeping personal information about you confidential.Some of your personal information is required by BMO Insurance for insurance purposes, such as considering and processing your application, administering a policy if issued, or investigating a claim. Access to your personal information is limited to those BMO Insurance employees and sub-contractors such as the paramedical provider who have a business need for it.

Proposed life insured

Proposed additional life insured

Do you agree to provide this information?

You are not eligible for this type of insurance coverage, do not proceed with this application. To learn more about your insurance options, please click here to contact a Certified Executor Advisor

(1) Do you understand the language (English) in which this application for insurance is written?

Language for policy and future correspondence:

(2) Are you a Canadian resident for income tax purposes?

If you answered ‘No’ you are not eligible for this type of insurance coverage, do not proceed with this application. To learn more about your insurance options, please click here to contact a Certified executor advisor

Step 2

Congratulations, you’re qualified so let’s get started! This won’t take long at all.

 
 
 
 

A smoker is someone who has used any form of tobacco, marijuana, hash or nicotine products at any time in the last 12 months

 
 
 
 

A smoker is someone who has used any form of tobacco, marijuana, hash or nicotine products at any time in the last 12 months

Step 3

Congratulations, you’re qualified so let’s get started! This won’t take long at all.

That last screen was the picky bit. The rest is much easier!

You have the option of choosing the current date for your policy or to choosing to back-date it in order to save money by basing the cost on a younger age. Consider that you'll have to pay the costs for the months you back-date, and will save money on all future payments.

For joint last-to-die policies, the cost of insurance is based on an equivalent single age, to reflect the longer mortality, which saves you money. Backdating may or may not affect the equivalent age if only one age is reduced, but will if both are. In your case, you would need to backdate more than 3 months, so current dating probably makes the most sense.

Beneficiary(ies) are the people who will receive the proceeds of your policy. You can name one or more, indicating the percentage for each. Irrevocable beneficiaries must authorize all future policy changes so only indicate irrevocable if you absolutely must. You can also named contingent beneficiaries to receive proceeds if your primary beneficiaries pre-decease you.

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Step 4

You’re already more than half way done!

Proposed life insured

Proposed additional life insured

Has any application, including any request to reactivate / reinstate any Life, Critical Illness, Long Term Care of Disability Insurance ever been declined, rated, postponed, cancelled, rescinded or modified in any way? (If yes, provide details in the comment space at the end.)

Is this insurance intended to replace or change any existing Life or Critical Illness Insurance with BMO Insurance or any other company?

(If Yes, please click here to contact a CEA to obtain a written analysis of the advantages and disadvantages of the proposed replacement. The Replacement Form or Life Insurance Replacement Declaration (LIRD) must be submitted with this application.)

Do you have, in effect or pending, any of the following: Life Insurance, Critical Illness Insurance, Disability Insurance or Long Term Care Insurance?

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Step 5

Please provide details for “yes” answers in the space provided, and if necessary, in the comments section at the end.

Proposed life insured

Proposed additional life insured

Have you used any form of tobacco, marijuana, hash, nicotine products or nicotine substitutes in the past 12 months?

Have you used any form of tobacco, marijuana, hash, nicotine products or nicotine substitutes in the past 24 months?

Have you used any form of tobacco, marijuana, hash, nicotine products or nicotine substitutes in the past 5 years?

Have you within the past 5 years flown as a pilot, student pilot, crew member or do you intend to do so?

If Yes, you’ll need to complete an Aviation Questionnaire. Please click here to email a CEA who can assist you.

Have you within the past 5 years participated in motor vehicle or power boat racing, scuba or skin diving, skydiving, hang gliding, ultra light flying, ballooning, rock climbing mountaineering, heli-skiing, back country skiing or any other similar sports of avocations or intend to do so?

If Yes, you’ll need to complete an Avocation Questionnaire. Please click here to email a CEA who can assist you

Have you traveled, resided, or worked outside North America in the past 12 months, or have any plans to do so in the next 12 months?

If Yes, Please provide details below

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Have you had more than two moving violations in the past 3 years? (ie: while driving)

If Yes, Please provide details below

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Have you had a license suspension, DUI (Driving Under the Influence) , or reckless driving conviction in the past 5 years?

Have you had a license suspension, DUI (Driving Under the Influence) , or reckless driving conviction in the past 10 years?

Have you ever been arrested, charged or convicted of any criminal offense?

Have you ever declared personal or corporate bankruptcy?

Step 6

Just a few more steps to go!

Proposed Life Insured

Proposed Additional Life Insured

Total Assets ($) :

Total Liabilities (Debts) ($) :

Net Worth ($) :

Annual Earned Income ($) :

Unearned Income (Other than wages, bonuses, commissions, etc) ($) :

Specify sources of unearned income (ie: investment, government benefits, etc)

If not gainfully employed, what is the gross amount (before tax) of the family income? ($)

If not gainfully employed, what is the amount of in-force insurance on the working spouse? ($)

Is there an existing or planned agreement that provides for anyone other than the Proposed Life Insured(s) or Owner(s) identified in the 'General Information' section (Third Party) to obtain any legal interest, pay the premiums or have an ownership interest in any policy resulting from this application?

To be completed by the Proposed Life Insured 1 / Proposed Additional Life Insured 2.

If additional space is needed, Proposed Insured 1 and, if applicable, Proposed Insured 2 must provide details on a separate sheet which is signed and dated.

BMO Life Assurance Company (Company) may make deductions, at any time, for regular recurring payments and/or one-time payments from time to time, from the bank account indicated in this application for insurance;

For the purpose of this agreement, all pre-authorized debits will be treated as Personal under the Canadian Payments Association rules (this means having 90 calendar days from the date any payment is processed to claim reimbursement for any unauthorized payment) ;

The withdrawal amount is considered to be variable under the Canadian Payment Association rules;

Any notices to be sent under this agreement may be sent to the proposed owner/owner’s most recent address that the Company has on record at the time the notice is sent;

The Company may charge a fee and may cancel the PAD for any withdrawal that is not honoured;

This authorization may be cancelled at any time upon the Company’s receipt of written notice by the payor;

All persons whose signatures are required to sign on this account have signed below, including any required joint account holder.

To waive the requirement that BMO Life Assurance Company notify them of:

This authorization before the first payment is processed, Any subsequent payments, and Any changes to the amount or date of the payment initiated by them or the Company.

Payors have certain recourse rights in the event that a debit does not comply with this agreement. Payors have the right to receive reimbursement for any debit that is not authorized or is not consistent with this PAD agreement. Payors may obtain a sample cancellation form or more information on rights to cancel this Authorization by contacting their financial institution or by visiting www.cdnpay.ca

Contact us at any time: BMO Life Assurance Company 60 Yonge Street Toronto, ON M5E 1H5 1-877-742-5244; Fax 416-596-0348

Signatures (We will obtain these from you later)

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September 19th, 2021