519-258-7733 jriolo@pbnet.ca

Life Insurance

Will your loved ones be taken care of if something happens to you? Contact us today to find out how you can ensure your family is covered if the unthinkable happens.
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Protect Your Family

We offer a variety of life insurance coverage tailored to your needs and the needs of your family.

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    Personal Information

    First Name Last Name
    Date of Birth Occupation
    Address Email

    My Health Is:

    Do you have a spouse? YesNo

    Spouse First Name Spouse Last Name
    Spouse Date of Birth Spouse Occupation

    My Spouse's Health Is:

    Home Phone (required) Mobile Phone (required) Preferred Contact Method
    Home PhoneCell PhoneEmail
    Combined Household Income Between $25K-$45KBetween $50K-$85KOver $100K

    Dependent Information

    Do you have any dependents? YesNo

    People Financially Dependent on you.

    Children

    Do you have any children? YesNo

    Number of Children
    If not now, are you planning to have children in the next 5 years? YesNo
    Smoker/Non-Smoker Height Weight
    SmokerNon-Smoker

    Are you currently taking any medication? YesNo

    If yes, please list your medications.

    Do you have a family doctor? YesNo

    If yes, enter your doctor's name.

    When was your last visit to your GP?

    Do you currently have life insurance? YesNo

    If yes, how much coverage?

    Do you currently have critical illness coverage? YesNo

    If yes, how much coverage?

    Do you currently have disability coverage? YesNo

    If yes, what is your monthly benefit?

    Do you plan to travel outside North America in the next 12 months? YesNo

    If yes, where will you be traveling?


    Contact Us

    Contact us today for a FREE quote.
    13013 Tecumseh Road East
    Windsor, ON N8N 3T4
    Tel: 519-258-7733
    jriolo@pbnet.ca

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