Company/Organization Name
 Number of Employees/Members

 First Name
 Last Name

 Your Position
 Email Address
 Address 
 City              Province  YT SK QC PE ON NU NT NS NL NB MB BC AB     Postal Code 
 Telephone Number

Do you currently have a group benefit provider? NoYes     
If so, who is it? 

 Yes, please have a member of the Law Assist Business Development team contact me about enrolling in the program.

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