To get a no-obligation quote for Disability Insurance, please complete the following form and submit it to our office. We will contact you within the next two business days. Please note that we can only provide insurance for residents of Ontario, Canada.
Your preferred means of communication for contact and follow-up :
E-mail
Phone
E-mail address :
Daytime telephone number :
Area 204 250 289 306 403 416 418 450 506 514 519 604 613 647 705 709 780 807 819 867 902 905 Ext. :
Home telephone number :
Area 204 250 289 306 403 416 418 450 506 514 519 604 613 647 705 709 780 807 819 867 902 905
Tell us about yourself...
Please Note : all fields must be completed for an accurate quote.
Name:
Address:
City:
Province:
Postal Code:
Sex
Male Female
Date of birth
(dd / mm / yyyy)
Occupation
Employer
Nature of business
Your duties
Income last year
Expected income this year
Are you eligible for Employment Insurance?
Yes No
Are you eligible for Workers' Compensation?
If you belong to a group insurance plan, enter the name of your group
Tell us what you want...
If you become sick or disabled, how soon should benefits start?
How long should benefits last?
Have you ever had your insurance cancelled or refused?
Tell us about your health...
Overall health
Good Poor
Have you smoked, or used any form of tobacco?
In the past 5 years Yes No
In the past year Yes No
If you quit smoking, when did you quit?
Date: Never:
Comment
Your Privacy You are authorizing that we collect, use or disclose your personal information contained on this information form as well as any additional information that we may obtain about you and other listed beneficiaries based on the information you have disclosed to us, (for example confirming your claims history or checking with motor vehicle agencies), for the purpose of providing you with this quote. By submitting this information form you also confirm that you have obtained the permission of all other potential beneficiaries listed on this information form for the collection, use and disclosure of their Personal Information for the purpose of providing you with this quote. Submission of this form does not constitute an application for insurance. Do you consent? Yes No
Thank you for taking the time to fill out this form. Select the "Submit" button below and we will contact you within the next two business days. Our quote will include the coverages you selected. We will include the cost of popular optional coverages with our quotation.
* Coverage is subject to the insurer's underwriting policies.
