Canadian Health, Drug & Dental Insurance Independent Broker & Advisor.

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E-Mail:
daniel.latour@
justincaseinsurance.com

MSN Messenger:(Live Chat)

latourdaniel@msn.com

Skype:
daniel.la.tour

Telephone:
1-514-630-6116

Toll Free Line:
1-888-977-7778

Toll-Free Fax:
1-888-637-2636

Mailing Address:
800 Rene-Levesque Ouest
P.O. Box 1408
Montreal, Quebec
CANADA H3B3L2

Regional Offices:
410-2001
McGill College Avenue
Montreal, Quebec
CANADA H3A1G1

200-1122 4 Street SW
Calgary, Alberta
CANADA T2R1M1

Guaranteed Issue Life Insurance to Protect Your Family

No Medical Exams

No Doctor's reports

No needles

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When you're not covered by a Company Group Plan, or your Province... You can apply for coverage the Province does not provide by filling in our quote form below. We are excited about our INSTANT ONLINE HEALTH, DRUG & DENTAL PLUS QUOTE & BUY capability provided by our partnership with Manulife Financial. CLICK HERE if you'd like to obtain an instant quote with Manulife Financial now. Or, if you would like us to shop with a variety of carriers, fill in the form below, we will do price comparisons, and e-mail or call you. Save Time & Money. Free, Fast & Easy To Apply. *Health, Drug & Dental Insurance Quick Quote* Your Personal Data:

Your Name:
Street Address:
City:
Province:
Postal Code:
E-Mail (REQUIRED):
E-Mail again for accuracy:
Phone:
Fax (optional):

Marital Status: Single Married	Homeowner? Yes No

Currently Insured? (If yes, list carrier, and # of years continuous. If none, type N/C)

Unusual Activities? (If you engage in unusual activities such as scuba diving, airplane flying, rock climbing, etc., list them here.)
Select Type of Plan You are Looking For:	Individual Plan Married with Spouse Included Family Plan

Underwriting Information:

Name of Insured:

Birthdate:

Sex (M/F): Smoker or
Non-Smoker?:

Height: Weight:

This best describes my personal situation:

	Visitor to Canada with Work Permit
	Canadian Waiting for Provincial Health Insurance
	Canadian Travelling Outside Home Province Inside Canada
	Canadian travelling Outside Canada
	Visitor in Canada without Provincial Health Insurance
	Self-Employed
	Request For Individual, Couple, Family Coverage
	Group Benefits Terminated
	Other
If other please specify

If adding spouse or family plan, list each person adding:

First Dependent Name:
Relationship:
Birthdate:
Smoker?

Second Dependent Name:
Relationship:
Birthdate:
Smoker?

Third Dependent Name:
Relationship:
Birthdate:
Smoker?

Fourth Dependent Name:
Relationship:
Birthdate:
Smoker?

Fifth Dependent Name:
Relationship:
Birthdate:
Smoker?

List Any Dental or Health Problems:

List Any Medication You Take:

Reason for Buying Insurance:

We offer the following features:

Prescription Drug Coverage
Preventive & Major Dental Care
Vision Care/Optometrist Fees
Health Care Professional Service Providers including:

Chiropractor, Psychologist, Physiotherapist, Acupuncturist
Registered Massage Therapist, Naturopath, etc

Ambulance, unlimited ground transportation to Hospital
Travel, up to $1 million emergency health coverage for trips
Much much more

Send my quotation via: E-Mail Fax
Regular Mail
Call Me by Phone

Thank you for filling out this form COMPLETELY!

We value your input as PRIVATE information. Every step has been taken to insure your privacy, security, and our intent is to release quote information only to you. We will not give your data to ANY other person or group for sales, marketing, or ANY other purpose. By checking the box below you agree to allow our agency to release this information via the method you have chosen, and to release us from any liability should this information be accidentally viewed by others.

Our intention is to maintain your complete privacy.

Yes, I Agree. Please Send Me a
Health Insurance Quote NOW!

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