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REQUEST FOR QUOTE

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I wish to obtain information relating to: *

Number of people covered by this enquiry:*

Are those services are already covered?*

Do you belong to a group served by Vigilis?*


Information on the firm

Firm name:*

Address:

City:

Province:

Postal code:

Contact person

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First name:*

Last name:*

Title:

E-mail:*

Telephone :*
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Fax:
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