Canadian Independent Visitors Insurance Broker & Advisor.

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E-Mail:
daniel.latour@
justincaseinsurance.com

MSN Messenger:(Live Chat)

latourdaniel@msn.com

Skype:
daniel.la.tour

1-888-977-7778 Monday-Friday 9-9, Saturdays 11-5, EST. Our International Number is: 1-514-630-6116

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

Courrier Address:
147 Place Terry Fox
Kirkland, Quebec
CANADA H9H 4Z5

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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Welcome Visitors To Canada We offer up to $150,000 CDN per person for Emergency Medical & Hospital Insurance Benefits We also offer you a comprehensive Benefit Plan that can include Life Insurance, Accidental Death & Dismemberment Benefits, Spousal Insurance, Dependent Insurance, Weekly Indemnity, Short Term/Long Term Disability Benefits, Comprehensive Medical & Prescription Drugs, Dental & Vision Care Benefits 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. 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:

	International Student studying in Canada
	Diplomat on assignment in Canada
	Visitor to Canada with Work Permit
	Visitor in Canada without Provincial Health, Drug & Dental Insurance
	Landed Immigrant without comprehensive Health, Drug & Dental Insurance
	Refugee without Provincial Health, Drug, & Dental Insurance
	Other

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:

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
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