web analytics

Next: Family Info




Name:
Email Address:
Type of Coverage: SingleCoupleSingle Parent Family
Provincial Health Coverage: Do you and all individuals seeking coverage, hold valid Ontario Health Insurance Plan (OHIP) Cards? Yes No
Sex of Primary Insured: Male Female
Date of birth of primary insured (DDMMYY):
Smoking status of Primary Insured: Smoker Non-Smoker
Height of Primary Insured (in Ft. & in.):
Weight of Primary Insured (Lbs):
Name of your spouse (if applicable):
Spouse’s sex (if applicable): Male Female
Spouse’s date of birth (DDMMYY):
Spouse’s smoking status: Smoker Non-smoker
Height of Spouse (in Ft. & in.):
Weight of Spouse (Lbs):
A dependent is defined as being under 21, unmarried, or under 25 if a full-time student. Please list the sex – name – age – height & weight of all eligible dependents below:
Please list the main reason you are seeking coverage, and list any current medications and costs here: