Health&Dental Insurance quotes

Your Health&Dental Insurance Quotes

	Manulife Financial
	Ontario Blue Cross
	Desjardins Financial Security
	The Edge
	Group Medical Services

Benefits Requested
Extended Health		Minimum	Medium	Enhanced Coverage
Prescription Drugs (Compare benefits)	None	Minimum	Medium	Enhanced Unlimited
Dental Care (Compare benefits)	None	Minimum	Medium	Enhanced Coverage
Vision Care	Yes	No	Not Important
Hospital (private or semi-private)	Yes	No	Not Important
Travel Insurance	Yes	No	Not Important
Critical Illness Insurance	Yes	No


		* represents mandatory fields
Applicant
Name*
Gender*		Male Female
Age*
Is Applicant a smoker ?*		Yes No

E-mail*
Phone Number
City *
Province*

Co-Applicant (Spouse) -		Plan for Family or Couple
Name
Gender *		Male Female
Age *
Is Co-Applicant a smoker ?*		Yes No

Dependent Children - Plan for Family or Single Parents
Number of dependent children**
Age of dependent children
Child 1	Child 2	Child 3	Child 4
Child 5	Child 6	Child 7	Child 8
**Children of 21-25 years of age must be full time students

When does your group plan expire? (if applicable) dd/mmm/yyyy

Notes and Questions

Please confirm your E-mail

Your quotes will be sent to your e-mail address within one business day.

If you have any questions or need help to complete the form please call Natalia at

416-493-0101, 1-877-443-0101

August 31, 2011