Canter Insurance Agency: Insurance Services

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Individual Plan Information Request

To obtain further information about Insurance and other Benefit Plans for Individuals, provide the following information and click the "Submit" button at the bottom of this form.

The fields displayed using bold text are required to submit.

First Name:
Last Name:
Street:
City:
State/Province:
Zip Code:
Telephone w/Area Code:
Fax w/Area Code:
E-mail Address:
Your Date of Birth:
Spouse's Date of Birth:

Please contact me via: (Check the method you prefer)
Telephone
FAX
E-mail
If you want to be contacted by telephone, select the best time to contact you:

Please select the plan(s) for which you would like to receive information. (Check all that apply.)

Individual Insurance and Other Benefit Plans
Request for Information

Health Care Plans
Dental Plans
Vision Plans
Long Term Nursing and Home Health Care Plans
Life Insurance Plans
Short Term Medical Plans
Medicare Supplementary Health Plans
Other:

Thank you for your request and input!

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Canter Insurance Agency
22147 Carinloch Street
Calabasas, California 91302
(818) 226-9255 (800) 726-2422
License #0787997
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