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E-Mail:
daniel.latour@
 justincaseinsurance.com

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

 
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Request To Quote For Long Term Care Insurance Benefits

Designed to cover the cost of health or personal care services resulting from an insured’s inability to care for himself/herself, due to a condition requiring care in the home or use of a long-term care facility. For more details click here

First Person's Information:

Desired Insurance:

Optional Benefits:
Return all premiums if you never claim:
Maintain daily benefit with cost of living:
Future Purchase Option:


Vital stats:
lbs.

Are you or is he/she currently a resident of Canada?

Ever been declined insurance or offered nonstandard rates?

Are you or is he/she currently taking any medications?
If yes, please describe Medical situation:


2nd Person's Information:

(If you selected to include a spouse...)

Desired Insurance:


Optional Benefits:
Return all premiums if you never claim:
Maintain daily benefit with cost of living:
Future Purchase Option:

Birth date:
vital stats:
lbs.

Complete 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.)
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 purposes. 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 Long Term Care Insurance Quote NOW!


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This page last updated December 8, 2007
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