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Your Guaranteed Issue Health & Dental  Insurance Quotes
No medical Questionnaire Required  (pre-existing conditions are covered) 

Manulife Financial

FlexCare ComboPlus Starter  

Base Health & Dental Plan

FlexCare Dental

Association Dental Plans

FollowMe (no questionnaire if you apply within 90 days of loss of your group benefits)

GMS

Replacement Health Coverage

(no questionnaire if your plan is effective within 60 days of loss your group benefits)

Ontario Blue Cross

Blue Vision Express Plan

 

Applicant

 

Name

Gender

Male      Female

Age

 

 

City

Province

 

 

E-mail

Phone Number

     (if you want a broker to call you)

 

 

Co-Applicant (Spouse)

- Plan for Family or Couple

Name

Gender

Male      Female

Age

 

 

Dependent Children

- Family Plan

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?                    dd/mmm/yyyy    (if applicable)

 

 

Notes and Questions

Please contact me to follow up with my quotes  by phone        by E-mail  

 

 

Please confirm your E-mail   

 

 

Your quotes will be emailed you within one business day.

 

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

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

 

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April 06, 2019