CMMOTA Accident Add On Application

APPLICATION FOR INSURANCE CANADIAN MASSAGE & MANUAL OSTEOPATHIC THERAPISTS ASSOCIATION Policy #1SN05

As a member of CANADIAN MASSAGE & MANUAL OSTEOPATHIC THERAPISTS ASSOCIATION, you are invited to participate in our group accident insurance program. Coverage applies for accidents (but not sickness) no matter when they occur.
Applicant Name*

First NameLast Name
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Phone Number*
Please enter a valid phone number.Format: (000) 000-0000.
Email*
example@example.com
Date of Birth

MonthDayYear
Date
YesNo
MaleFemale
YesNo
I hereby enrol in the above-noted program.
Date Signed*

MonthDayYear
Date
Signature*
For further information, contact:

Rob Barlow B. Admin, CAIB, CIP

Dusyk & Barlow Insurance

Brokers Ltd.

4615 Albert Street

Regina, SK S4S 6B6

Phone: (306) 789-8384, (800) 305-6737

FAX: (306) 525-8540

Email: sales@saskinsurance.com

https://www.saskinsurance.com
Please verify that you are human*
Should be Empty:

APPLICATION FOR INSURANCE CANADIAN MASSAGE & MANUAL OSTEOPATHIC THERAPISTS ASSOCIATION Policy #1SN05