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Primary Applicant
Prefix
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Mr.
Mrs.
Ms.
Mx.
Miss
Dr.
Prof.
First Name
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Middle Name
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Last Name
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Date of Birth
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MM
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DD
/
YYYY
Are you employed?
Full time (work more than 25 hours a week)
Part time (work less than 25 hours a week)
Casual or self-employed
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Job Description
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Gross annual salary (before tax)
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Are you smoking? (Vaping, e-cigarettes, and nicotine gum are considered smoking)
Yes
No
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Have you smoked within the last 12 months?
Yes
No
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