Please tell us how you found our website (Which search engine, advertisement, Other?)
Telephone number (with area code) (*optional) :
Please enter the first three (3) digits of your postal code:
Are you a smoker?:
Yes
No
Do you live in Ontario?
Yes
No
No
Yes
Do you live in Quebec?
Your Spouse's Name (if applicable):
Your Spouse's Date of Birth (If applicable):
Your Date of Birth:
Your e-mail address (ie. you@aol.com)
First & last name
Personal Information
To receive a free no obligation Quotation by email, simply fill out ALL of the required fields. An estimation of your premium will be e-mailed back to you at the e-mail address provided.
Disability Insurance Quote
What is your annual income (4)?:
What is your Occupation?:
What are your duties (Please be specific.)?:
Are you:
self employeed
an employee
Are you covered by Employment Insurance?:
Yes
No
If your Disability Insurance need is for Business, such as key-person or shareholers Insurance, please provide the same information as above for each additional person.
Any other information which you feel may be of importance or further questions, please enter in the space below.
Additional Financial Products
Besides our Commercial and Personal insurance products, we also have various types of financial products. If you would like further information on any of the Financial Products listed below, simply select it:
Group Insurance
Yes
No
No
Yes
Health Insurance
Dental Insurance
Yes
No
No
Yes
Vision Care
RRSP's
Yes
No
No
Yes
RRIF's
Annuities
Yes
No
No
Yes
Retirement Plans
Estate Planning
Yes
No
No
Yes
Charitable Giving
Over
40
years in business serving all of eastern Ontario and west Quebec