Request Form

Through you Standard Life Assistance Program, you can schedule a counselling session, get workplace support, and much more.

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Policy Information

Policy number
Certificate number


I am a/an

Policy holder Dependent / Child
Name of policy holder
Date of birth of policy holder
(yyyy-mm-dd)


What can we do for you?

I would like to schedule for counselling.
I have questions on services.
I have questions on eligibility.
I have other questions.

Comments



Please tell us a little about yourself.

Company Name
Job Category()
First name
Last name
Birth Date
Email
Phone
Ext
Preferred Time for calls
Is it okay to leave voice messages?
Yes No
City
Province/State



We offer our clients the opportunity to provide feedback on our services and their experience through online surveys. May we email you a survey to the address provided?

Yes No