Doctors Manitoba | Extended Healthcare and Dental Application

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Extended Healthcare and Dental Application

Step 1

Enrollment Information
Step 2

Authorization and Consent
Step 3

Banking Information

Application for Voluntary Health & Dental Benefits

This section to be completed by member.

First Name *

Last Name *

Mailing Address *

City *

Province *

Postal Code *

Email *

Phone Number *

Member's Date Of Birth *

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

If yes, please indicate

Benefits Covered

Health

Vision

Ambulance

Dental

Drugs

HSA

Hospital

Name of Insured

Name of Insurance Company

Please provide any additional details about alternate coverage.

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Application for Voluntary Health & Dental Benefits