Fillable (COMPLETE SECTIONS 124567)

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*11201* GROUP INSURANCE APPLICATION (COMPLETE SECTIONS 124567) MODIFICATIONS TO GROUP INSURANCE 11201 (COMPLETE SECTIONS 123467 AND 5, IF APPLICABLE) La Capitale Insurance and Financial Services Inc. GROUP NO. 625 SaintAmable St, PO Box 1500, Quebec QC G1K 8X9 418 6444200 or 1 800 4634856 Fax: 418 6461313 adm.collectif lacapitale.com EMPLOYER NO. IDENTIFICATION NO. 6000 1 Information about the participant GROUP...
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