The information I request is
needed to help answer your insurance questions. It is and will be kept
confidential and used only to help you with your insurance concerns.
Please complete the form so insurance needs can be matched
with appropriate plan. Most insurance plans are complex enough to require
discussion so please be certain your phone number and E-mail address are
How soon do you want to be contacted?
What is the best time and phone number to call you?
What types of insurance are you concerned about? Check all
Health & Dental Plans
Semi or Private Hospital Coverage (also included in above)
Travel Insurance (including Visitors to Canada)
Various Types of Life Insurance (including Mortgage Insurance)
Disability Insurance (Loss of Income due to Accident or Sickness)
Critical Illness (lump sum payment on diagnosis)
Long Term Care (LTC)
Registered Education Saving Plan
Registered Retirement Saving Plan
For whom are you inquiring? (self, Mother, Father, etc.)
Where does (or will) the person reside for whom the
insurance is being questioned or considered?
List any special insurance or health circumstances you feel should be considered: