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Medical Management Quote Request Form
 
Quote Request For:

Company Name: *
Industry Sector:
Contact Name: *
Address:
City:
Province/State: *
Phone: *
Fax:
Email: *

Number of Employee's:
What are your Medical costs:
Company Doctor:
Company Nurse:
HR Department Contact:
Injury Type:
Type of Medical Insurance Claims
Do you require all our services?:

Please indicate which of the following documents below you can submit to our office via fax (905-891-3710). The more information you can provide will only assist us in creating a more accurate quote based on your requirements.
Neer Statement:
Accident Cost Statement:
Cad-7 Statement:
Map Statement:
WCB Cost Premiums Statements Worldwide

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