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What type of insurance do you need?^*

Choose your preferred insurance type

Life Insurance

Salary/Disability Insurance

Mortgage Insurance

Critical Illness Insurance

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Fill in this information to help us personalize your plan

Your Sex^*

Male

Female

Are you a smoker?^*

Yes

Date of birth^*

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Amount of coverage desired per month?^*

Choose the amount of coverage you need

$0 – $1,000 / month

1,000$ - 2,500$/month

2,500$ - 5,000$/month

5,000$/month and more

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Amount of coverage desired?^*

Choose the amount of coverage you need

0 – $1,000$

1,000$ - 2,500$

2,500$ - 5,000$

5,000$ and more

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Duration of coverage^*

Choose your duration of coverage

10 years

15 years

20 years

25 years

30 years

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Which best describes your current occupation?

Business Owner

Self-Employed / Freelancer

Professional / Specialist

Student

Retired

Not Currently Employed

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A few details about your loan

Loan amount^*

Mortgage term in years^*

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Personal Information^*

First Name^*

Last Name^*

Email^*

Phone Number^*

City^*

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Consent^*

I consent to the collection and use of my personal informationin accordance with the privacy policy and I agree that my information may beshared with accredited professionals. Privacy Policy.

I accept the privacy policy.

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Thank you! Your request has been received!

In the next few business hours, our assistant will contact you to:

• Confirm certain information
• Answer your initial questions
• Schedule a personalized call with a specialist advisor

This quick exchange allows us to properly prepare your case and offer you options tailored to your situation.

If you do not receive a call within 24 business hours, you can reach us at 514-743-5963 .

Looking forward to exchanging ideas with you.

—
The Assure Québec team

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