Let’s talk – EVAC24

Thanks for your interest in our insured products.

Please tell us in the form below as much as possible about your business and the people you wish to cover. The form has some autocomplete fields but your email needs to be verified by OTP before we can receive your request.

Please complete all fields

Cover type you are interested in

Group Cover required

Number of individuals in your group to be covered

Your Group Information

Group / Organisation Name

Referral Party's Information

[one_half] Full Name [/one_half]

[one_half] Position/Job Title [/one_half]

Referral Party's Contact Details

[one_half] Cellphone Number [/one_half]

[one_half] Your email address [/one_half]

Enter email verification OTP here

Group Geographic Information

Physical Address

[one_half] Closest Major City [/one_half]

[one_half] Province [/one_half]

Group's Background

How was the group formed and how does it function?

List only yes and a brief description of the disability. If none please write only Not Applicable

Are there any pre-existing disabilities of any of the Group's members:

Group's access to resources (contact ability)

Physical resources: please select all that apply to you

InternetComputerTelephoneOfficeOther

Other physical resources worth mentioning

Emergency Contact Details (other than the Referral Party)

[one_half] Contact Person [/one_half]

[one_half] Contact number [/one_half]