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Health Coverage Choice - Buy online
Application for Health Coverage Choice
Your province:
-Select-
Alberta
British Columbia
Manitoba
New Brunswick
Newfoundland
Northwest Territory
Nova Scotia
Nunavut
Ontario
Prince Edward Island
Quebec
Saskatchewan
Yukon
Online purchase of Health Coverage Choice is not available in Quebec.
An advisor can help you apply.
Please provide the following information:
You, the applicant
First name
Initial
Last name
Sex
Date of birth
(dd/mm/yyyy)
male
female
Your spouse
First name
Initial
Last name
Sex
Date of birth
(dd/mm/yyyy)
male
female
Child 1
First name
Initial
Last name
Sex
Date of birth
(dd/mm/yyyy)
male
female
Child 2
First name
Initial
Last name
Sex
Date of birth
(dd/mm/yyyy)
male
female
Child 3
First name
Initial
Last name
Sex
Date of birth
(dd/mm/yyyy)
male
female
Child 4
First name
Initial
Last name
Sex
Date of birth
(dd/mm/yyyy)
male
female
Plan:
Health and Dental Choice A
Health Choice B
Health Choice C
Payment:
monthly (from your bank account or credit card)
annual (from your credit card)
Price:
$0.00
Your address:
City:
Province:
Postal code:
Home telephone:
(including area code)
Work telephone
(Optional)
:
ext:
E-mail address:
