More Information

In order to meet your unique needs, I will need to ascertain your individual or business circumstances before offering any quotations.

Please contact me to discuss your needs, or if you prefer you may fill in the information form at the link below and I will contact you.

Confidential Health and Welfare Census Data Form

• For individuals, please include yourself and your spouse and/or childeren.
• For group insurance, please include every employee, and their spouses and/or children.

For Company Group Insurance, please complete our Group Insurance Quote Request and Census form.

As a part of the standard fact-finding process, please be prepared to provide the following information when we contact you.

• Your Name, Phone Number, contact email address, sex and birth date
• Occupation (% administravie in office, % supervision, % field, sales, etc)
• Are you a Business Owner (yes/no)
• Health History (counseling & chiropractic are relevant)
• Whether you have ever been treated for any of the following: Cancer, High Blood Pressure, Diabetes, Asthma, Immune System Disorders, Depression/Anxiety, Heart Disease, Drug/Alcohol Abuse, Epilepsy, or similar conditions.
• Whether you take medications and if so, provide a list.
• Tobacco Use (yes/no)
• Hazardous Activities
• Why you want this insurance
• A list any other insurances in force now