General Information

Mr.Mrs.

*First name :

*Last name :

*Phone :

*City :

*Firm's name :

Applicant

*Do you belong to a group, association or professional order ?YesNo

If yes, which group, association or professional order do you belong to?

What kind of coverage are you interested in ?Income ProtectionOverheadBuy/Sell Insurance

*Are you or have you ever been one of our clients ?YesNo

Contact Preferences

When do you want us to call you ?MondayTuesdayWednesdayThursdayFriday

Between 8h30 a.m. and 12h00 p.m.Between 1 p.m. and 5 p.m.

Stay connected

Email:

I hereby authorize Lussier Dale Parizeau to send me information about its products and services by email (I will be able to modify my permission at any time):

Special offers, saving opportunities, contestsYesNo

Newsletter (general information and advice about the company and products)YesNo

Questions / Comments

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