Proposed Insured: Date of Birth: Policy Number:
1. PURPOSE OF INSURANCE:
qEstate Conservation qCapital Gains/Estate Tax qMortgage Insurance
qIncome Continuance qOther – describe:
2. How was the amount of insurance determined? (attach copies of relevant calculations, if available):
3. INSURANCE IN FORCE:
Describe purpose of Business Insurance now in force:
Personal Income and Net Worth
Please attach any additional comments you feel are relevant to the financial underwriting of this application.
I declare that the above answers and statements are full, complete and true and shall form part of
my application for insurance with The Equitable Life Insurance Company of Canada.
Date Witness Proposed Insured
CONFIDENTIAL FINANCIAL QUESTIONNAIRE PERSONAL COVERAGE
Head Office
One Westmount Road North
P.O. Box 1603 Stn. Waterloo, Ontario N2J 4C7
TF 1.800.722.6615 F 519.883.7422
E indnewbus@equitable.ca
PERSONAL BUSINESS GROUP COMPANY DATE ISSUED
Life $ $ $ $
AADB $ $ $ $
ANNUAL INCOME
EARNED
Salary (or Draw)
$
Plus Bonus & Comm.
$
Other Earnings
$
Total Earned Income
$
UNEARNED
Dividends, Rentals,etc.
$
Total Income
$
ASSETS
Cash
Business Equity
$
Other (stocks,real estate etc.)
$
Total Assets
$
LIABILITIES
Mortgages & Personal Loans
$
Total Liabilities
$
Net Worth
$
1324 (2008/01/22 )
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