Doctors Manitoba | Extended Healthcare and Dental Application

Application for Voluntary Health & Dental Benefits

This section to be completed by member.

First Name *

Last Name *

Home Address *

City *

Province *

Postal Code *

Email *

Phone Number *

Member's Date Of Birth *

Please note that you must be under age 70 to apply for coverage (some exceptions do apply)

Member's Gender *

Male

Female

Provincial Health Number *

Yes

Please complete this section if you have eligible dependents.

Please indicate

Spouse

Common-law

Last Name

First Name

Date of Birth

Gender

Male

Female

If Applicant and Spouse are not legally married please provide commencement date of cohabitation.

Add any unmarried dependent children below.

Last Name *	First Name *	Relationship *	Date of Birth (YYYY-MM-DD) *	Gender *

Coverage Applied For: *

Members must enroll according to their true family status. Once enrolled, members may not opt out (except in the event of duplicate group coverage).

Health

Dental

Do you or your dependents have coverage for any of the benefits applied for through another insurance plan? *

Yes