Get A Quote

Although we expect to offer coverage to the majority of applicants declined by other insurers, there are certain impairments or combinations of impairments that will not be considered. Please refer to the Uninsurable Impairments before proceeding to collect an application.
To obtain a quote, please provide us with as much of the information requested below as you can. The more detailed information you provide, the more accurate our quote will be.

Note that only the fields marked with an asterisk (*) are mandatory.

If you require assistance, please call us at:
Direct: 416-322-7268, ext. 1 or
Toll Free 1-888-995-9199, ext. 1





Information About Your Client/Potential Applicant





Requires no use of tobacco or related products for at least 12 months.




Heightfeet/inches or
cm

Weightpounds or
kg



Approximate Date of Diagnosis  Month
Year




Approximate Date of Diagnosis  Month
Year






Approximate Date of Decline  Month
Year










Acceptional Life® is a trade-mark of Co-operators Life Insurance Company and is used under licence.