Member Contact Information Form

Member Contact Information Form
Please complete the form below to receive plan information *required fields

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

1. Blue Cross, Comprehensive Express Health Plan (Optional Dental) from $56.95 monthly.

2. Sun Life Financial Basic, Standard & Enhanced Health and Dental from $61.45 monthly

3. Sun Life Financial Critical Illness Insurance (Coverage from $10,000 to $2,000,000)

4. Sun Life Financial Term Insurance (Coverage from $50,000)

5. Sun Life Financial Long Term Care Insurance (Coverage from $150.00 to $2,000.00 weekly)

6. Comprehensive Health/Dental (Premier Plan) from $207.25 monthly

7. Comprehensive “Private Health Savings Plan” (Tax Savings Plan)

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)

Thank you!

Serving Realtors for over 20 years.