60 days limited offer

until August 31st, 2008

Information requested about Disability Insurance (Guaranteed Standard Issue). This program is available for graduating students of Leslie Dan Faculty of Pharmacy – University of Toronto. The 2008 Start Right Program is underwritten by The Great-West Life Assurance Company.

* Name of graduating student:
Sex:
Smoker status:
Birthday:	/ / Year
Address:
City:
Province:
Postal code:
* Phone:
* E-mail:
Do you have any individual, association, group or other disability insurance in force?
Are any applications for individual, association, group or other disability insurance pending or contemplated?
Have you ever been treated for or had any known indication of partial or total loss of vision or hearing, impaired speech or paralysis, amputation, deformity or loss of use of either or both hands or feet?
Have you ever had an application for individual disability insurance declined?
Have a specific question/comment:

We are committed to respecting the confidentiality of the information provided in this request and will use this information solely for providing a quote on the Start Right Program available to 2008 graduating students of Leslie Dan Faculty of Pharmacy – University of Toronto. Questions about 2008 Start Right Program? This limited offer is underwritten by Great-West Life and managed by Diane A. Gagné Financial Services. If you have any particular questions about 2008 Start Right Program, please call at 1-877-243-8845 ext. 309 or by e-mail : jmvachon@dianeagagne.com .

60 days limited offer

Questions about 2008 Start Right Program?