Fillable *11201* MEMBERSHIP APPLICATION GROUP INSURANCE MODIFICATIONS TO GROUP INSURANCE 11201 La Capitale Insurance and Financial Services Inc

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*11201* MEMBERSHIP APPLICATION GROUP INSURANCE MODIFICATIONS TO GROUP INSURANCE 11201 La Capitale Insurance and Financial Services Inc. group no. employer no. identification no. 625 SaintAmable St., P.O. Box 1500, Quebec QC G1K 8X9 418 6444200 or 1 800 4634856 Fax: 418 6461313 adm.collectif lacapitale.com 6000 1 INFORMATION RELATING TO PARTICIPANT NAME OF THE GROUP RETIREMENT DATE EMPLOYERS NAME BEFORE RETIREMENT...
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