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Plan Type

Have You Reviewed Plans with One of Our Brokers?

Name *

First

Last

Phone *

Email *

What Coverage Would You Like on Your Plan?

Extended Health Coverage
Dental Coverage
Prescription Drug Coverage
Vision Care
Paramedical Specialist Coverage
Disability Insurance
Life Insurance
Travel Insurance

Number of Children

Date of Birth

Height

Weight

Do You Have a Family Physician?

Name of Family Physician

Date of Last Physician Visit

Reason for Last Physician Visit and Details of Condition/Treatment (if any)

Spouse's Name

Spouse's Date of Birth

Spouse's Height

Spouse's Weight

Spouse - Date of Last Physician Visit

Spouse - Reason for Last Physician Visit and Details of Condition/Treatment (if any)

Child 1 - Name

Child 1 - Date of Birth

Child 1 - Height

Child 1 - Weight

Child 1 - Date of Last Physician Visit

Child 1 - Reason for Last Physician Visit and Details of Condition/Treatment (if any)

Child 2 - Name

Child 2 - Date of Birth

Child 2 - Height

Child 2 - Weight

Child 2 - Date of Last Physician Visit

Child 2 - Reason for Last Physician Visit and Details of Condition/Treatment (if any)

Child 3 - Name

Child 3 - Date of Birth

Child 3 - Height

Child 3 - Weight

Child 3 - Date of Last Physician Visit

Child 3 - Reason for Last Physician Visit and Details of Condition/Treatment (if any)

Child 4 - Name

Child 4 - Date of Birth

Child 4 - Height

Child 4 - Weight

Child 4 - Date of Last Physician Visit

Child 4 - Reason for Last Physician Visit and Details of Condition/Treatment (if any)

List All Children's Names/Dates of Birth/Height/Weight/Date of Last Physician Visit/Reason for Last Physician Visit

Save and Resume Later

Are Any of the Applicants on Any Prescription Medication?

Applicants Name/Medication Name/Medical Condition/Dosage/Length of Treatment

Are the prescriptions refillable?

Have Any of the Applicants Consumed any Nicotine, Tobacco, Alcohol or Cannabis Products in the Last 12 Months?

Applicants Name/Details of Daily/Weekly or Monthly Consumption Habits

Have Any of the Applicants Ever Received or Been Advised to Undergo Treatment or Counselling for Drug/Alcohol Abuse?

Applicants Name

In the Last 2 Years, Have Any of Applicants Used Unregulated Substances (Street Drugs)?

Applicants Name

Are Any of the Applicants Currently Pregnant?

Applicant Name / Weeks Pregnant

Have Any of the Applicants Ever had Symptoms of Any Chronic Cardiovascular Conditions

Stroke/CVA, Transient Ischemic Attack, Heart Attac, Angina, High Blood Pressure, Chest Pains, Palpitations, Heart Murmur, High Cholesterol...

Applicant Name/Details of Condition/Treatment

Have Any of the Applicants Ever had Symptoms of Any Respiratory System Issues

Asthma, Chronic Bronchitis, Cystic Fibrosis, Emphysema, COPD, Sleep Apnea...

Applicants Name/Details of Condition/Treatment

Have Any of the Applicants Ever had Symptoms of Any Digestive System Issues

Ulcerative Colitis, Chron's Disease, Hepatitis, Chronic Pancreatitis, IBS....

Applicant Name/Details of Condition/Treatment

Have Any of the Applicants Ever had Symptoms of Any Chronic Issues with the Kidneys, Bladder or Reproductive Organs

Applicant Name/Details of Condition/Treatment

Have Any of the Applicants Ever had Symptoms of Any Chronic Neurological Condition

Parkinson's, Multiple Sclerosis, Chronic Headaches, Dizziness, Vertigo, Epilepsy, Paralysis...