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Health Coverage Choice - Buy online
Application for Health Coverage Choice
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
Your province:
-Select-
Alberta
British Columbia
Manitoba
New Brunswick
Newfoundland
Northwest Territory
Nova Scotia
Nunavut
Ontario
Prince Edward Island
Quebec
Saskatchewan
Yukon
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: