Blue Cross Contact Information Form

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Contact Information Form
Please complete the form below to receive Plan Information and Plan Rates *required fields

Please supply me with a quotation/information on the following plan (check one or more):

1. Blue Cross Deluxe Express Health Plan from $25.25 monthly

2. Blue Cross Basic Express Health Plan from $19.30 monthly

3. Blue Cross Starter Express Health Plan from $13.10 monthly

4. Blue Cross Seniors Express Health Plan from $31.00 monthly

OPTIONAL ADD-ON BENEFITS TO ANY ONE OF YOUR 4 NEW HEALTH PLANS:

1. Prescription Drug Plan ( 80% to $1,500.00 per calendar year)

2. Dental Plan including Major Restorative (80% to $1,250.00 per calendar year)

3. Deluxe Home Health Care

4. PROHEALTH Cancer Insurance Plan
(Issue age up to age 80, benefits vary from $1,000.00 to a maximum of $20,000.00.
Single payment - Tax-Free Benefit)

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5. Annual Travel coverage to age 80

Member Mailing Information:

*Name:

Address 1:

Address 2:

City:

Province:

(Select from list)

Postal Code:

Member Phone and E-mail Information:

*Telephone:

fax:

*e-mail:

*Date of Birth

(for cost comparison)

I am a:

Smoker

Non-Smoker

Questions or Comments: (Please specify to your information/product request)

What is the best time to contact you? (check one from each column)

Morning	Weekday
Afternoon	Weekend
Evening

Thank you!

Serving Realtors for over 20 years.