Personal information

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Personal information

Province of residence: Québec Modify my province of residence

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Type of coverage

Single  
Couple  
Single parent  
Family  

Provincial Health Coverage

Do you and all individuals seeking coverage, hold valid Quebec Health Insurance Plan (Medicare) Cards? Yes No

Details of the individuals to insure

Primary Insured
Sex Age Height Smoker 
M
F
 m or  ft  in
Smoker
Weight
Non-smoker
 kg or  lb

Employment Status of the primary insured

Student
Self-employed
Working without access to group insurance coverage
Retired (early or otherwise)
Other - specify   

Email address