| What type of coverage(s) are you most interested in? (check all that apply): |
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: |
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| If there are exising medical conditions and drug costs, please explain in detail: |
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Employment Status (check all applicable):
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Self-employed
Employee
have employees that may want coverage
Incorporated business
Unincorporated Business
Retired
Unemployed
On Disability
Other |
| Name: |
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| Email Address: |
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| Phone number |
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