Health Plus™ Insurance Application APPLICANTDEPENDENTSSTATEMENT OF HEALTHSTATEMENT OF HEALTH CONT'DSTATEMENT OF HEALTH CONT'DINSURANCE HISTORYPERSONAL DECLARATIONPRE-AUTHORIZED PAYMENT Please answer all questions and sign where indicated on pages 7 and 8.After you submit your completed Application, you can download a copy for your files.If you have any questions about the information required, please contact us. APPLICANT Name * Date of Birth Gender Male Female Street Address Unit / Apt. / Suite City Province Postal Code Residence Phone * Cellular Phone Business Phone Email Address * Occupation Employer Employer Address Are you a member of an Association offering Health Plus as a membership benefit? No Yes Name of Association Health Plus Plan Choice Optimum Priority Requested Coverage Single Couple Single Parent Family If you are applying for Couple, Single Parent or Family Coverage, please complete the Dependents information below. Next If you are human, leave this field blank.