Tester page - BrokerForce Insurance

test form

tester

How did you find out about BrokerForce Insurance?

i.e. Google Search, Social Media, Referral (please let us know who referred you), etc.

I NEED A QUOTE FOR A SECOND APPLICANT AS WELL.

Name(Required)

First Last

APPLICANT 2 - Name(Required)

First Last

Date of Birth(Required)

APPLICANT 2 - Date of Birth(Required)

Gender(Required)

Female

Male

Other

APPLICANT 2 - Gender(Required)

Female

Male

Other

How would you like us to Contact you?(Required)

Phone

Email or Phone call are fine

Email(Required)

Phone Number(Required)

Primary Canadian Address(Required)

Street Address Address Line 2 City Province Postal Code

Primary Destination of Travel(Required)

Date of Departure(Required)

Date of Return(Required)

Please select your age range

0 - 59 years old

60+ years old

APPLICANT 2 - Please select your age range

0 - 59 years old

60+ years old

SMOKER STATUS

In the last two (2) years, have you smoked cigarettes, and/or used vaping products or e-cigarettes?(Required)

Yes

APPLICANT 2 - In the last two (2) years, have you smoked cigarettes, and/or used vaping products or e-cigarettes?(Required)

Yes

PART 1 - RATE QUALIFICATION

Have you ever been diagnosed with or treated for a heart condition?(Required)

Yes

APPLICANT 2 - Have you ever been diagnosed with or treated for a heart condition?(Required)

Yes

Have you ever been diagnosed with or treated for any of the following conditions; Aortic aneurysm (including thoracic or abdominal aneurysm), Cirrhosis of the liver, Parkinson's disease, or Alzheimer's disease or other form of dementia?(Required)

Yes

APPLICANT 2 - Have you ever been diagnosed with or treated for any of the following conditions; Aortic aneurysm (including thoracic or abdominal aneurysm), Cirrhosis of the liver, Parkinson's disease, or Alzheimer's disease or other form of dementia?(Required)

Yes

In the last three (3) months, have you taken or been prescribed a total of three (3) or more medications for high blood pressure (hypertension)?(Required)

Yes

APPLICANT 2 - In the last three (3) months, have you taken or been prescribed a total of three (3) or more medications for high blood pressure (hypertension)?(Required)

Yes

In the last five (5) years, have you been diagnosed with, taken or been prescribed medication for, or been treated for any of the following:

Lung condition (except unrepeated prescription medications used for single episode) (medication includes any puffer(s)/inhaler(s)?(Required)

Yes

APPLICANT 2 - Lung condition (except unrepeated prescription medications used for single episode) (medication includes any puffer(s)/inhaler(s)?(Required)

Yes

Stroke or mini-stroke/TIA (transient ischemic attack) (medication includes use of aspirin/Entrophen for this condition)?(Required)

Yes

APPLICANT 2 - Stroke or mini-stroke/TIA (transient ischemic attack) (medication includes use of aspirin/Entrophen for this condition)?(Required)

Yes

Diabetes (if treated with medication and/or insulin)?(Required)

Yes

APPLICANT 2 - Diabetes (if treated with medication and/or insulin)?(Required)

Yes

Narrowed or blocked artery in the legs or in the neck?(Required)

Yes

APPLICANT 2 - Narrowed or blocked artery in the legs or in the neck?(Required)

Yes

PART 2 - RATE QUALIFICATION

In the last two (2) years, have you been diagnosed with, taken or been prescribed medication, or been treated for any of the following conditions:

Bowel obstruction or surgery?(Required)

Yes

APPLICANT 2 - Bowel obstruction or surgery?(Required)

Yes

Diverticular disorder requiring prescription medication or surgery?(Required)

Yes

APPLICANT 2 - Diverticular disorder requiring prescription medication or surgery?(Required)

Yes

Gastrointestinal bleeding?(Required)

Yes

APPLICANT 2 - Gastrointestinal bleeding?(Required)

Yes

Chronic bowel disorder?(Required)

Yes

APPLICANT 2 - Chronic bowel disorder?(Required)

Yes

Liver disorder?(Required)

Yes

APPLICANT 2 - Liver disorder?(Required)

Yes

Pancreatic disorder?(Required)

Yes

APPLICANT 2 - Pancreatic disorder?(Required)

Yes

Kidney disorder (including stones)?(Required)

Yes

APPLICANT 2 - Kidney disorder (including stones)?(Required)

Yes

Gallbladder disorder? (including stones. If gall bladder has been removed, answer NO)(Required)

Yes

APPLICANT 2 - Gallbladder disorder? (including stones. If gall bladder has been removed, answer NO)(Required)

Yes

In the last two (2) years, have you been diagnosed with, and/or been treated by a Hematologist or an Internist for a blood disorder or a blood disease?(Required)

Yes

APPLICANT 2 - In the last two (2) years, have you been diagnosed with, and/or been treated by a Hematologist or an Internist for a blood disorder or a blood disease?(Required)

Yes

In the last six (6) months, have you received advice or treatment for a medical emergency more than twice in the emergency room of a hospital?(Required)

Yes

APPLICANT 2 - In the last six (6) months, have you received advice or treatment for a medical emergency more than twice in the emergency room of a hospital?(Required)

Yes

Are you over 70, and have you had a fall for which you sought medical attention in the last six (6) months?(Required)

Yes

APPLICANT 2 - Are you over 70, and have you had a fall for which you sought medical attention in the last six (6) months?(Required)

Yes

If you answered “YES” to ANY of the questions in Part 2, you qualify for Rate Category B. If you answered “NO” to ALL of the questions in Part 2, you qualify for Rate Category A.

In the last four (4) months, have you taken or been prescribed seven (7) or more prescription medications? Do not count the following medications: hormone replacement therapy (thyroid or menopausal); drugs used for osteoporosis, or traveller’s diarrhea; or any form of immunization. Do not count topical medications that go in your nose, ears or eyes or on your scalp or skin except any form of nitroglycerine or any drug(s) for angina.(Required)

Yes

APPLICANT 2 - In the last four (4) months, have you taken or been prescribed seven (7) or more prescription medications? Do not count the following medications: hormone replacement therapy (thyroid or menopausal); drugs used for osteoporosis, or traveller’s diarrhea; or any form of immunization. Do not count topical medications that go in your nose, ears or eyes or on your scalp or skin except any form of nitroglycerine or any drug(s) for angina.(Required)

Yes

In the last twelve (12) months, have you had:

A new heart condition, or an existing heart condition for which you had a change in medication or were hospitalized (as an inpatient or seen in the emergency department)?(Required)

Yes

APPLICANT 2 - A new heart condition, or an existing heart condition for which you had a change in medication or were hospitalized (as an inpatient or seen in the emergency department)?(Required)

Yes

Shortness of breath or chest pain for which you sought treatment?(Required)

Yes

APPLICANT 2 - Shortness of breath or chest pain for which you sought treatment?(Required)

Yes

Lung condition for which you were hospitalized (as an inpatient or seen in the emergency department) or for which you have taken or been prescribed prednisone?(Required)

Yes

APPLICANT 2 - Lung condition for which you were hospitalized (as an inpatient or seen in the emergency department) or for which you have taken or been prescribed prednisone?(Required)

Yes

Cancer or received chemotherapy and/or radiotherapy and/or other treatment, other than routine follow-up, for cancer (except basal cell and squamous cell skin cancer, and breast cancer treated only with hormonal therapy)?(Required)

Yes

APPLICANT 2 - Cancer or received chemotherapy and/or radiotherapy and/or other treatment, other than routine follow-up, for cancer (except basal cell and squamous cell skin cancer, and breast cancer treated only with hormonal therapy)?(Required)

Yes

In the last two (2) years have you been diagnosed with, taken or been prescribed medication, or been treated for heart failure or congestive heart failure?(Required)

Yes

APPLICANT 2 - In the last two (2) years have you been diagnosed with, taken or been prescribed medication, or been treated for heart failure or congestive heart failure?(Required)

Yes

APPLICANT 2 - In the last two (2) years have you been diagnosed with, taken or been prescribed medication, or been treated for heart failure or congestive heart failure?(Required)

Yes

APPLICANT 2 - In the last two (2) years have you taken or been prescribed Lasix or furosemide or a water pill for ankle or leg swelling or water on the lungs?(Required)

Yes

In the last three (3) years, have you been diagnosed with, taken or been prescribed medication, or been treated for any two (2) of the following:

A heart condition?(Required)

Yes

APPLICANT 2 - A heart condition?(Required)

Yes

A lung condition? (except for unrepeated prescription medications used for a single episode); medication includes any puffer(s)/inhaler(s)(Required)

Yes

APPLICANT 2 - A lung condition? (except for unrepeated prescription medications used for a single episode); medication includes any puffer(s)/inhaler(s)(Required)

Yes

A stroke or mini-stroke/TIA (transient Ischemic attack) including the use of aspirin/Entrophen for the condition?(Required)

Yes

APPLICANT 2 - A stroke or mini-stroke/TIA (transient Ischemic attack) including the use of aspirin/Entrophen for the condition?(Required)

Yes

Diabetes (treated with medication and/or insulin)(Required)

Yes

APPLICANT 2 - Diabetes (treated with medication and/or insulin)(Required)

Yes

Narrowed or blocked artery in the legs (also called Peripheral Vascular Disease)(Required)

Yes

APPLICANT 2 - Narrowed or blocked artery in the legs (also called Peripheral Vascular Disease)(Required)

Yes

Have you had a heart bypass, coronary angioplasty or heart valve surgery more than ten (10) years ago?(Required)

Yes

APPLICANT 2 - Have you had a heart bypass, coronary angioplasty or heart valve surgery more than ten (10) years ago?(Required)

Yes

In the past 6 months, have you been prescribed, refilled or taken prescription medication, other than birth control, low-dose aspirin, or antibiotics?(Required)

Yes

APPLICANT 2 - In the past 6 months, have you been prescribed, refilled or taken prescription medication, other than birth control, low-dose aspirin, or antibiotics?(Required)

Yes

In the past 6 months, have you been prescribed, refilled or taken prescription medication for:

Blood pressure(Required)

Yes

APPLICANT 2 - Blood pressure(Required)

Yes

Stoke/mini-stroke (TIA), or prevention of a blood clot?(Required)

Yes

APPLICANT 2 - Stoke/mini-stroke (TIA), or prevention of a blood clot?(Required)

Yes

A heart condition? (Heart condition means any condition relating to the heart or cardiovascular system)(Required)

Yes

APPLICANT 2 - A heart condition? (Heart condition means any condition relating to the heart or cardiovascular system)(Required)

Yes

A digestive condition? (Digestive condition means any condition related to the heart or cardiovascular system)(Required)

Yes

APPLICANT 2 - A digestive condition? (Digestive condition means any condition related to the heart or cardiovascular system)(Required)

Yes

A lung/respiratory condition (excluding allergies)? (Lung/respiratory condition means any condition related to the lung or respiratory system)(Required)

Yes

APPLICANT 2 - A lung/respiratory condition (excluding allergies)? (Lung/respiratory condition means any condition related to the lung or respiratory system)(Required)

Yes

Diabetes or pre-diabetes?(Required)

Yes

APPLICANT 2 - Diabetes or pre-diabetes?(Required)

Yes

Have you been diagnosed with or had any cancer treatment in the past 6 months? (This does not include basal or squamous cell skin cancer or breast cancer treated only with hormone therapy.)(Required)

Yes

APPLICANT 2 - Have you been diagnosed with or had any cancer treatment in the past 6 months? (This does not include basal or squamous cell skin cancer or breast cancer treated only with hormone therapy.)(Required)

Yes

Have you used any tobacco or nicotine products in the past 6 months?(Required)

Yes

APPLICANT 2 - Have you used any tobacco or nicotine products in the past 6 months?(Required)

Yes