General Information

M.Mme

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*Name:

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Additional Information

What is the name of your co-proprietorship union?

How many units are there in your co-proprietorship?

What is your policy renewal date?

Contact Information

What is your preferred method of contact?TelephoneEmail

If you wish to be contacted by telephone, which of the following times is most convenient for you?MondayTuesdayWednesdayThursdayFriday

Between 8:30 AM-12:00 PMBetween 1:00 PM-5:00 PM

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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

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