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Office:
(902) 648-3434
Toll Free:
1-855-768-4771
Fax:
(902) 648-3334
Email:
admin@delagency.com
P.O. Box 9
4075 Route 308
Tusket, Nova Scotia
B0W 3M0
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Fields marked with an * are mandatory.
Your Contact Details:
* Name:
* Preferred Phone:
* Email Address:
* Preferred Contact Method:
Email
Phone
* Postal Code:
* Community:
Your Requirements:
Coverage for:
You
You & Your Partner
Type of Cover:
Select
Life Insurance
Term Life Insurance
Permanent Life Insurance
Critical Illness Insurance
Disability Insurance
Mortgage Insurance
Supplemental Life Insurance
Funeral Insurance
Over 65 Life Insurance
Accidental Death & Dismemberment Insurance
Insurance for New Immigrants
No Medical Life Insurance
Amount of Cover:
Select
$20000
$25000
$30000
$35000
$40000
$45000
$50000
$55000
$60000
$65000
$70000
$75000
$80000
$85000
$90000
$95000
$100000
$105000
$110000
$115000
$120000
$125000
$130000
$135000
$140000
$145000
$150000
$155000
$160000
$165000
$170000
$175000
$180000
$185000
$190000
$195000
$200000
$205000
$210000
$215000
$220000
$225000
$230000
$235000
$240000
$245000
$250000
$255000
$260000
$265000
$270000
$275000
$280000
$285000
$290000
$295000
$300000
$305000
$310000
$315000
$320000
$325000
$330000
$335000
$340000
$345000
$350000
$355000
$360000
$365000
$370000
$375000
$380000
$385000
$390000
$395000
$400000
$405000
$410000
$415000
$420000
$425000
$430000
$435000
$440000
$445000
$450000
$455000
$460000
$465000
$470000
$475000
$480000
$485000
$490000
$495000
$500000
$550000
$600000
$650000
$700000
$750000
$800000
$850000
$900000
$950000
$1000000
$1100000
$1200000
$1300000
$1400000
$1500000
$1500000+
About You:
Health Condition:
Excellent
Good
Date of Birth:
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Do you Smoke?
No
Yes
Have you been denied insurance before?
No
Yes
Questions/Comments:
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By submitting this form you agree to speak to a licensed & accredited Life Insurance Advisor who will provide you with a FREE, NO OBLIGATION quote.
