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Step
1
of 2
Name
*
First
Last
Email
*
Phone
*
Number of Applicants
Date of Birth
*
Gender
Female
Male
Other
Name of the Secondary Applicant
Date of Birth of the Secondary Applicant
Gender of thew Secondary Applicant
Female
Male
Other
Name, Gender and Date of Birth of All Applicants
Next
Coverage Start Date
Coverage End Date
Deductible
$0
$75
$500
$1,000
$2,500
$5,000+
Do Any of the Applicants have Pre-Existing Medical/Health Conditions or Complication?
No
Yes
Any existing and ongoing prescriptions? Any ongoing health treatments? Anaphylactic Allergies? Health-Related Impediments?
Country/State of Origin
Canada
Afghanistan
Albania
Algeria
Andorra
Angola
Anguilla
Antigua & Barbuda
Argentina
Armenia
Australia
Austria
Azerbaijan
Bahamas
Bahrain
Bangladesh
Barbados
Belarus
Belgium
Belize
Benin
Bermuda
Bhutan
Bolivia
Bosnia & Herzegovina
Botswana
Brazil
Brunei Darussalam
Bulgaria
Burkina Faso
Myanmar/Burma
Burundi
Cambodia
Cameroon
Cape Verde
Cayman Islands
Central African Republic
Chad
Chile
China
Colombia
Comoros
Congo
Costa Rica
Croatia
Cuba
Cyprus
Czech Republic
Democratic Republic of the Congo
Denmark
Djibouti
Dominica
Dominican Republic
Ecuador
Egypt
El Salvador
Equatorial Guinea
Eritrea
Estonia
Ethiopia
Fiji
Finland
France
French Guiana
Gabon
Gambia
Georgia
Germany
Ghana
Great Britain
Greece
Grenada
Guadeloupe
Guatemala
Guinea
Guinea-Bissau
Guyana
Haiti
Honduras
Hungary
Iceland
India
Indonesia
Iran
Iraq
Israel and the Occupied Territories
Italy
Ivory Coast (Cote d'Ivoire)
Jamaica
Japan
Jordan
Kazakhstan
Kenya
Kosovo
Kuwait
Kyrgyz Republic (Kyrgyzstan)
Laos
Latvia
Lebanon
Lesotho
Liberia
Libya
Liechtenstein
Lithuania
Luxembourg
Republic of Macedonia
Madagascar
Malawi
Malaysia
Maldives
Mali
Malta
Martinique
Mauritania
Mauritius
Mayotte
Moldova
Monaco
Mongolia
Montenegro
Montserrat
Morocco
Mozambique
Namibia
Nepal
Netherlands
New Zealand
Nicaragua
Niger
Nigeria
North Korea
Norway
Oman
Pacific Islands
Pakistan
Panama
Papua New Guinea
Paraguay
Peru
Philippines
Poland
Portugal
Puerto Rico
Qatar
Reunion
Romania
Russian Federation
Rwanda
Saint Kitts and Nevis
Saint Lucia
Saint Vincent's & Grenadines
Samoa
Sao Tome and Principe
Saudi Arabia
Senegal
Serbia
Seychelles
Sierra Leone
Singapore
Slovakia
Slovenia
Solomon Islands
Somalia
South Africa
South Korea
South Sudan
Spain
Sri Lanka
Sudan
Suriname
Swaziland
Sweden
Switzerland
Syria
Tajikistan
Tanzania
Thailand
Timor Leste
Togo
Trinidad & Tobago
Tunisia
Turkey
Turkmenistan
Turks & Caicos Islands
Uganda
Ukraine
United Arab Emirates
United States of America (USA)
Uruguay
Uzbekistan
Venezuela
Vietnam
Virgin Islands (UK)
Virgin Islands (US)
Yemen
Zambia
Zimbabwe
Province of Origin
Newfoundland
Nova Scotia
New Brunswick
Prince Edward Island
Quebec
Ontario
Manitoba
Saskatchewan
Alberta
British Columbia
Yukon
Northwest Territories
Nunavut
Do You Have Any Government Health Coverage?
No
Yes
Which Country/State is Providing the Coverage?
Canada
Afghanistan
Albania
Algeria
Andorra
Angola
Anguilla
Antigua & Barbuda
Argentina
Armenia
Australia
Austria
Azerbaijan
Bahamas
Bahrain
Bangladesh
Barbados
Belarus
Belgium
Belize
Benin
Bermuda
Bhutan
Bolivia
Bosnia & Herzegovina
Botswana
Brazil
Brunei Darussalam
Bulgaria
Burkina Faso
Myanmar/Burma
Burundi
Cambodia
Cameroon
Cape Verde
Cayman Islands
Central African Republic
Chad
Chile
China
Colombia
Comoros
Congo
Costa Rica
Croatia
Cuba
Cyprus
Czech Republic
Democratic Republic of the Congo
Denmark
Djibouti
Dominica
Dominican Republic
Ecuador
Egypt
El Salvador
Equatorial Guinea
Eritrea
Estonia
Ethiopia
Fiji
Finland
France
French Guiana
Gabon
Gambia
Georgia
Germany
Ghana
Great Britain
Greece
Grenada
Guadeloupe
Guatemala
Guinea
Guinea-Bissau
Guyana
Haiti
Honduras
Hungary
Iceland
India
Indonesia
Iran
Iraq
Israel and the Occupied Territories
Italy
Ivory Coast (Cote d'Ivoire)
Jamaica
Japan
Jordan
Kazakhstan
Kenya
Kosovo
Kuwait
Kyrgyz Republic (Kyrgyzstan)
Laos
Latvia
Lebanon
Lesotho
Liberia
Libya
Liechtenstein
Lithuania
Luxembourg
Republic of Macedonia
Madagascar
Malawi
Malaysia
Maldives
Mali
Malta
Martinique
Mauritania
Mauritius
Mayotte
Moldova
Monaco
Mongolia
Montenegro
Montserrat
Morocco
Mozambique
Namibia
Nepal
Netherlands
New Zealand
Nicaragua
Niger
Nigeria
North Korea
Norway
Oman
Pacific Islands
Pakistan
Panama
Papua New Guinea
Paraguay
Peru
Philippines
Poland
Portugal
Puerto Rico
Qatar
Reunion
Romania
Russian Federation
Rwanda
Saint Kitts and Nevis
Saint Lucia
Saint Vincent's & Grenadines
Samoa
Sao Tome and Principe
Saudi Arabia
Senegal
Serbia
Seychelles
Sierra Leone
Singapore
Slovakia
Slovenia
Solomon Islands
Somalia
South Africa
South Korea
South Sudan
Spain
Sri Lanka
Sudan
Suriname
Swaziland
Sweden
Switzerland
Syria
Tajikistan
Tanzania
Thailand
Timor Leste
Togo
Trinidad & Tobago
Tunisia
Turkey
Turkmenistan
Turks & Caicos Islands
Uganda
Ukraine
United Arab Emirates
United States of America (USA)
Uruguay
Uzbekistan
Venezuela
Vietnam
Virgin Islands (UK)
Virgin Islands (US)
Yemen
Zambia
Zimbabwe
Which Province is Providing the Coverage?
Newfoundland
Nova Scotia
New Brunswick
Prince Edward Island
Quebec
Ontario
Manitoba
Saskatchewan
Alberta
British Columbia
Yukon
Northwest Territories
Nunavut
Country/State of Residence
Afghanistan
Albania
Algeria
Andorra
Angola
Anguilla
Antigua & Barbuda
Argentina
Armenia
Australia
Austria
Azerbaijan
Bahamas
Bahrain
Bangladesh
Barbados
Belarus
Belgium
Belize
Benin
Bermuda
Bhutan
Bolivia
Bosnia & Herzegovina
Botswana
Brazil
Brunei Darussalam
Bulgaria
Burkina Faso
Myanmar/Burma
Burundi
Cambodia
Cameroon
Cape Verde
Cayman Islands
Central African Republic
Chad
Chile
China
Colombia
Comoros
Congo
Costa Rica
Croatia
Cuba
Cyprus
Czech Republic
Democratic Republic of the Congo
Denmark
Djibouti
Dominica
Dominican Republic
Ecuador
Egypt
El Salvador
Equatorial Guinea
Eritrea
Estonia
Ethiopia
Fiji
Finland
France
French Guiana
Gabon
Gambia
Georgia
Germany
Ghana
Great Britain
Greece
Grenada
Guadeloupe
Guatemala
Guinea
Guinea-Bissau
Guyana
Haiti
Honduras
Hungary
Iceland
India
Indonesia
Iran
Iraq
Israel and the Occupied Territories
Italy
Ivory Coast (Cote d'Ivoire)
Jamaica
Japan
Jordan
Kazakhstan
Kenya
Kosovo
Kuwait
Kyrgyz Republic (Kyrgyzstan)
Laos
Latvia
Lebanon
Lesotho
Liberia
Libya
Liechtenstein
Lithuania
Luxembourg
Republic of Macedonia
Madagascar
Malawi
Malaysia
Maldives
Mali
Malta
Martinique
Mauritania
Mauritius
Mayotte
Moldova
Monaco
Mongolia
Montenegro
Montserrat
Morocco
Mozambique
Namibia
Nepal
Netherlands
New Zealand
Nicaragua
Niger
Nigeria
North Korea
Norway
Oman
Pacific Islands
Pakistan
Panama
Papua New Guinea
Paraguay
Peru
Philippines
Poland
Portugal
Puerto Rico
Qatar
Reunion
Romania
Russian Federation
Rwanda
Saint Kitts and Nevis
Saint Lucia
Saint Vincent's & Grenadines
Samoa
Sao Tome and Principe
Saudi Arabia
Senegal
Serbia
Seychelles
Sierra Leone
Singapore
Slovakia
Slovenia
Solomon Islands
Somalia
South Africa
South Korea
South Sudan
Spain
Sri Lanka
Sudan
Suriname
Swaziland
Sweden
Switzerland
Syria
Tajikistan
Tanzania
Thailand
Timor Leste
Togo
Trinidad & Tobago
Tunisia
Turkey
Turkmenistan
Turks & Caicos Islands
Uganda
Ukraine
United Arab Emirates
United States of America (USA)
Uruguay
Uzbekistan
Venezuela
Vietnam
Virgin Islands (UK)
Virgin Islands (US)
Yemen
Zambia
Zimbabwe
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