Full Name
Email
Phone Number
Street Number and Name
Unit Number (If applicable)
City
Province
Alberta
British Columbia
Manitoba
New Brunswick
New Foundland and Labrador
Nova Scotia
Ontario
Prince Edward Island
Quebec
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Northwest Territories
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Postal Code
Country
SIN Number
Date of Birth
What is your citizenship?
What is your employment status?
Employed
Self Employed
Retired
Not Employed
Student
What company do you work for?
What is your occupation?
What industry is your employment?
What is your employer's address
Please upload a photo of the front of driver's license.
Full Name
Email
Phone Number
If no, fill in address below with postal code and country.
SIN Number
Date of Birth
What is your citizenship?
What is your employment status?
Employed
Self Employed
Retired
Not Employed
Student
What company do you work for?
What industry is your employment?
What is your occupation?
What is your employer's address
Please upload a photo of the front of driver's license.
Client After Tax Monthly Income
Partner After Tax Monthly Income
Any Rental Income
Any Canada Child Benefit, Spousal/Child Support, or Government Income?
List any additional income sources:
List any debt(s):
Home Value
Mortgage Balance
Interest Rate
Renewal Date
Mortgage and/or Rent (and frequency)
Property Tax
Strata/Condo/Maintenance Fees
Home Insurance
Utilities
Mobile Phone Service
Internet/Cable Service
Home Maintenance
Vehicle Insurance
Vehicle Lease or Loan
Vehicle Repairs/Maintenance
Gas
Transit
Groceries
Pets
Hobbies
Health/Fitness
Personal/Clothing
Subscriptions
Entertainment and Eating Out
Gifts
Spousal/Child Support
Bank Fees
Child Care
Other:
Life Insurance
Critical Illness
Disability
Group Insurance/Extended Benefits
RRSP
TFSA
Non-Registered Invesment
What are your top three financial goals?
How long until you reach your first goal?
What is NOT working for you right now when it comes to your finances?
What is most important to you about your finances?
I have read and agree to the following terms and conditions for the collection of my personal information?
Advisor Disclosure
Licensing - I, Lane Cuthbert, am a licensed life insurance agent in the Province of British Columbia. I am also an ordained minister and legal representative for the Province of British Columbia to carry a marriage license. As such, I officiate a small number of weddings each year.
Companies I Represent - I currently hold broker contracts with the following companies: Manulife Financial, Empire Life, Equitable Life, Canada Life, Canada Protection Plan, Humania (Hugo), Desjardins, Sunlife, Ivari, RBC, SLi, BMO, SSQ, iA Assurance, myHSA, Manulife bank, and ISI.
Relationship with the Companies I Represent - No insurance company holds an ownership interest in my business, nor do I hold an interest in any insurance company.
Compensation - If you choose to purchase a financial product through me, I will be paid a sales commission from the company that issues the product. Although I earn a commission when you purchase financial products, it is sound financial strategy and not just products which help you to achieve financial success. I charge a fee for strategy design work, but this fee is discounted if you go on to implement strategies and products under my guidance.
I may receive a renewal (or service) commission if you keep your financial products for years to come. I may also be eligible for additional compensation, such as bonuses or non-monetary benefits like travel incentives, depending on factors like the volume or consistency of business I generate over a given time period. While I am paid commissions by insurance companies, no insurance company holds an interest in my business. Your financial goals are my first priority.
More Information - If you’d like more information about my qualifications or the nature of my business relationships, please email my team.
Privacy Statement
I endeavour to maintain the highest standards of confidentiality in dealing with client information and I adhere to the Personal Information and Electronic Documents Act (“PIPEDA”), a federal privacy law.
Accountability - My company is responsible for the personal information I receive from my clients and I abide by the principles of PIPEDA in safeguarding that information in hard copy and computer documents. My employees also understand and abide by these rules.
Collection Purposes, Limitations on Collection, Use, Disclosure and Retention - Any and all identity, health, corporate and financial information is collected and kept solely for the purpose of providing advice and to ensure that any products or services you purchase through me are provided quickly and correctly. In order to obtain products for you, I am required to convey your information to insurers through wholesale organizations confidentially. I only collect and retain information that helps me formulate advice and service the products you purchase through me.
Consent - The nature of my work means I must receive and retain a lot of personal information about my clients including health data, financial data and identity verification. I use this information to make judgments about your situation and to identify possible solutions to problems you might have. In becoming my client, you agree to give me this information, allow me to share this information with relevant financial companies and intermediaries, and you allow me to retain your information in my paper and electronic files for as long as you wish me to be your advisor or as long as I have a business or legal need to retain the information. Should I retire, die or become incapacitated, you allow me to transfer your file information, including your personal information, to another agent or agency, to continue to service your needs. However, you have the right to choose a different agent if you wish. You also agree to receive electronic communications or Commercial Electronic Messages (CEMs) from me. You may withdraw your consent at any time.
Information Accuracy - I rely on receiving accurate information in order to make appropriate recommendations. You may review the personal information I retain about you upon request. I may also update the information regularly in an effort to ensure I am making recommendations about your situation based on the correct information.
Safeguards - All the written information I receive from you is either in secure filing cabinets or in password protected computer files. Any computer files stored off-site are military-grade encrypted or locked. Old files that are discarded are shredded or otherwise completely destroyed. My staff understands the sensitivity of this information and the importance of protecting it.
Questions, Concerns and Access - You may contact me at any time by telephone, email or letter at the address shown on this page about your files with me and request changes.You may review PIPEDA online at www.privcom.gc.ca.If you have any complaints about my procedures I will investigate and provide you with a response as soon as practical. A full copy of my Privacy Policy is available upon request.
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