Better Business Bureau

Personal Group Insurance: Online Enrolment

Instructions:

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  • Each employee must be enrolled using this application form.
  • Once we have received your enrolment request(s) we will:
    • Check for errors and create an application form per employee.
    • Contact you to obtain any additional information that might be required.
    • Send you or the employees the PDF application for their signature.
Company name:
To enroll multiple employees please click here:
* not required
Part A - General Information
Applicant first name:
Applicant initial: * Last name:
Apt. No:  * Street: 
City/town: 
Province:
Postal Code: 
Occupation: 
Marital Status:   (Determines if there is a co-applicant)
Applicant Phone: 
Applicant Email:
Applicant Sex:
Health Card #:
Applicant DOB:   Day:
Month:
Year:       Age:
Smoker?   If yes, how many cigarettes per day?
Height:  
Weight:  
Weight Change in Last Year:      Reason for Weight Change:
Part B - Dependants to be Covered
Number of Insured Dependants:
Part C - Beneficiary Designation
- Beneficiaries are for Accidental Death and Dismemberment (AD&D) if applicable -
- if you are not sure about this you can skip this step for now -

Applicant Beneficiary:
Last Name: First Name: % of Benefit:
Relationship to applicant:
If you appoint a beneficiary under the age of 18, benefits will be paid into court or to Public Trustee unless a trustee is appointed below.
Applicant Trustee:
Last Name: First Name:

Finish Enrolment