Last Name
First Name
Middle Initials
Apt / Unit #
Street Address
City
Province
Postal Code
Home Phone (Include Area Code)
Other (Include Area Code
Email
Secondary Email
Birthday
Age
Gender
Beneficiary
Phone (Include Area Code)
Relationship
Emergency
Phone (Include Area Code)
Relationship
Individual Enrollment
Reinstatement
Coverage Applying For:
Provincial Standard PlanGuaranteed Issue
Provincial Enhanced PlanGuaranteed Issue
Provincial Diversified PlanGuaranteed Issue
Dependant Information 18 Years of Age or Younger - $14.50 per dependant child
1st Child
Last Name
First Name
M. Initial
Gender
Birthday
2nd Child
Last Name
First Name
M. Initial
Gender
Birthday
3rd Child
Last Name
First Name
M. Initial
Gender
Birthday
Add Child
Complimentary Items
Will & Power of Attorney Kits
CPP Form
Airline Compassionate Form
Additional Benefits
Core Program
$25,000 Accident & living benefits, plus 15 enhancements
Emergency Health Data Card
This life saving Data Card can be carried in your wallet or purse and can be accessed by doctors, care facilities, hospitals and emergency personnel worldwide.
Subtotal:

Order Summary

Subtotal:

I Want to Pay:

Disclosure Acknowledgement
The provision of the following information is a requirement of the Financial Institutions Act. Your licensed agent is assisting you in obtaining a Benefits Plan. These plans are underwritten by various Insurance Companies. Your licensed agent has a brokerage or single case agreement under the terms of which, the agent is able to market the products and services of a number of Companies. The agent will receive a commission as a result of the transaction paid by these companies. The Financial Institutions Act prohibits tied selling. Your Agent may use any information received from you to make you aware of other financial products and services that may be of interest.
I confirm that I have read and understand this Disclosure Acknowledgement from my agent, and I consent to the procedures regarding handling of information described in this application.