Critical Illness

Name:
Address:
City:
Province:
Postal Code:
Phone number:
Email:
Insured #1
Name:
Date of Birth:
Are you a smoker:	YesNo
Type of Insurance:
Amount of Coverage:
Insured #2
Name:
Date of Birth:
Are you a smoker:	YesNo
Type of Insurance:
Amount of Coverage:

Russ Bastow Insurance

68 Church Street S.
Ajax, Ontario L1S 6B3

Tel: 905-231-2017 / 1-866-227-8691
Fax: 905-427-3039
Email: inquiries@bastowinsurance.com