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REQUEST FOR QUOTE

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I wish to obtain information relating to Superclub Vidéotron Franchisees Group Insurance.

Contact person

 Mr.     Mrs.

First name:*

Last name:*

Title:

E-mail:*

Telephone:*
- Ext.

Fax:
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Information on the firm

Firm name:*

Address:

City:

Province:

Postal code:

Information on the firm (cnt'd)

Business sector:

Number of years in business:

Number of employees (+20h/week):*

Is group coverage currently in force?*

Employer contribution to total premium (min. 25%):

Number of pay periods:

Must the plan cover employees from other companies?
 Yes     No     I don't know

Are any employees presently absent from work on disability, parental of other authorized leave?
 Yes     No     I don't know

* I hereby acknowledge to have read the information about the Vigilis Group.

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