Peek-a-Boo Plan Application Form

Make sure that you consult the Description of Coverage, including the exclusions as well as the procedure for filing a claim.

Yes, I would like to take advantage of the Peek-a-Boo Plan providing free accident insurance for 12 months*. I understand that this offer does not involve any other obligation on my part. Please bring me my accident insurance policy, as well as the attractive night light included with the offer.

* Mandatory information
Your first name*
Your last name*
Civic no. and street*
Apartment no.
Post Office Box
City*
Province*
Postal code*
Telephone no.*	(  )  -
E-mail
How did you hear about the Peek-a-Boo plan?*     through the www.mamanpourlavie.com website     other, specify:
Child's date of birth (DD/MM/YYYY)	January February March April May June July August September October November December
Expected date of delivery (DD/MM/YYYY)	January February March April May June July August September October November December
Child's first name
Child's last name
Child's sex	Girl      Boy
Reserved for Administration only Agent code Agency code
You will receive your accident insurance policy and the night light in four to six weeks.
This form is secure. For further information, consult the Confidentiality section.