Benefit Survey & Contact Form

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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
What Province are you living in?:	Ontario Alberta
‘Other’ coverage or explanations:
Do you currently have an existing benefit plan?:
Please explain exisiting coverage (if applicable):
If there are exising medical conditions and drug costs, please explain in detail:
Employment Status (check all applicable):	Self-employed Employee have employees that may want coverage Incorporated business Unincorporated Business Retired Unemployed On Disability Other
Would you be interested in looking into disability insurance as part of your package?:
Name:
Birthdate:
Name of additional family members (& birthdates):
Email Address:
Please list your contact phone numbers (and best time to call):
If you are interested in considering the insurance industry, please attach your resume. We are always happy to discuss career opportunities. Thank you for your survey response! We look forward to helping you in any way we can! Craig