Health Benefits Card

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Application for: Health Benefits Card

Important Note: Please use your legal name when applying for the Benefit Card. Include a copy of the birth.

CERTIFICATE AND STATUS CARD/OR CITIZENSHIP CARD. If Parents are applying on Behalf of the Children, Please Enter Status numbers below and Provide a Copy of the Card of BOTH parents. For a name change, send a copy of your MARRIAGE
CERTIFICATE or your NEW BIRTH CERTIFICATE.

Please ensure the Citizenship being entered is for the applicant and not that of their parent

Status

New Member
Replacement Card
Change of Information

Name *

First

Last

Sex *

Male
Female

Please select the Community for Registration

Date of Birth *

CARRIER ID: 11 GROUP #: 051364 CANADA LIFE #:

Health Care Number

Email *

Phone

Address

Address Line 1

Address Line 2

City

State / Province / Region

Postal Code

Country

Additional Information:

Mother's Name *

First

Last

Status/Citizenship #

Father's Name *

First

Last

Status/Citizenship#

(For Office Use Only)

Date Received

Date Card Ordered