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Looking for?:




What type of coverage(s) are you most interested in? (check all that apply): Travel insurance (Canadian travelling abroad)

Travel ("Snowbird")

Travel Insurance (New Immigrant to Canada without government health care)

Medical appliances &/or professional services (eg. massage therapy, physiotherapy, chiropractor)

Prescription drugs

Dental care

Vision Care

Disability Insurance

Life Insurance

Long term care

Other (explain in box below)

Group coverage possible for above choices
If you or your spouse became unable to work due to a medical condition, injury, or death, what would be important to you (check all that apply): Would want the mortgage paid

Would want daily expenses covered

Would not want to move or downsize

Would not want to earn less money
Please tell us any other details that brought you to us:

If there are exising medical conditions and drug costs, please explain in detail:

Employment Status (check all applicable):
 		Self-employed

Employee

have employees that may want coverage

Incorporated business

Unincorporated Business

Retired

Unemployed

On Disability

Other
Name:

Email Address:

Phone number