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#1
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#2
Insured's Name:
Date of Birth:
Calendar
Tobacco Use:
Select
Never
Quit < 12 months ago
Quit 1-5 years ago
Quit > 5 years ago
Currently smoke
Only cigars/pipe
Marijuana use
Amount of Insurance:
Sex:
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Male
Female
Health:
Select
Excellent
Good
Fair
Poor
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
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