Welcome to D.G. Smith Insurance & Financial Services

Office Hours
Monday - Thursday 9am - 5pm
Friday 9am - 4pm
Saturday and Sunday by appointment only

Home

Quote Request

Please fill out the Life Insurance Quote form if you are looking for a quote on Life Insurance, Disability Insurance and/or Critical Illness Insurance. Begin by filling out Section I then you may proceed to fill out the sections that you would like to receive a quote on.

SECTION I - General Information
How did you hear about us?
Name:	(required)
Address:
City:	(required)
Province:
Postal Code:	(required)
Phone Number:	(required)
Email Address:
Preferred Method of Contact:
Date of Birth:
Sex:
Are you a smoker :	Yes No

SECTION II - Life Insurance
Type of Life Insurance :
Amount of coverage needed :
If Term Insurance chosen, please choose term:

SECTION III - Disability Insurance
Occupation:
Amount of coverage needed monthly:
How long is coverage needed for:

SECTION IV - Critial Illness
Amount of Lump sum benefit:

Comments:

Limitation of Liability

Investment Disclaimer

Investor Privacy

304 Toronto Street South, Suite #204, Elgin Centre, Uxbridge, ON L9P 1Y2
P: (905) 852-5691 | inquiries@dgsmithinsurance.com | Toll Free: 1-800-377-4784

© 2007 D. G. Smith Insurance & Financial Services
Web design by Virtual Office Support