Quote Form - Supplemental Insurance

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Affordable Coverage

Once the form is completed you should
receive your quote within 24 hours.

This is a personalized quote; not automated, and based on the information provided.

Name
First Last
Email*
Phone
AGE*
Please enter a number from 1 to 69.
AGE*
Please enter a number from 16 to 69.
AGE*
Please enter a number from 18 to 70.
Where did you hear about us?
- Referred personally
- Facebook
- Instagram
- Newspaper
- Other
Thanks for trusting us with your insurance needs!
We're sorry. This product is only available for persons over the age of 15
*
- Male
- Female
Medical History*
Have you received any medical advice or treatment, or taken prescription medication within the past 5 years for:
- Heart Attack
- Stroke
- Cancer
- Diabetes

Completion of a health qualification questionnaire will be required before application is submitted.
- Yes
- No
Are you a smoker or non-smoker?
- Smoker
- Non-smoker
Parents can purchase this policy for their children, aged 6 months and older.
Family plans are available at increased savings.
Dependents between the ages of 15 days and 17 years inclusive
Family plans are available at increased savings.
Dependents between the ages of 15 days and 17 years inclusive
Check box if Proposed Insured is a minor (under 18 yrs)
- Yes
Estimated Grossly Income*
Selection*
- I'm looking for Accident-only coverage
- I'm looking for Sickness-only coverage
- I'm looking for both Accident and Sickness coverage
Height Feet & Inches (Ex: 5' 6")*
Weight lbs*
Within the past five (5) years, have you consulted a health care professional, undergone a medical exam, diagnostic tests, surgery, or been diagnosed with or prescribed medication, or been recommended to have treatment by physician for any of the following health problems:
a. Heart attack, angina, atrial fibrillation, congestive heart failure, coronary artery disease that requires bypass surgery, a stent or angioplasty, or heart valve replacement?*
- Yes
- No
b. Stroke, transient ischemic attack (TIA) ?*
- Yes
- No
c. Cancer, melanoma, Hodgkin's disease or leukemia?*
- Yes
- No
d. Multiple Sclerosis, Cystic Fibrosis, Muscular Dystrophy or Down's Syndrome?*
- Yes
- No
e. Alcoholism or drug addiction?*
- Yes
- No
f. Diabetes which requires insulin, or Diabetes which was diagnosed prior to age 40?*
- Yes
- No
g. Have you ever had any positive test, treatment for or exposure to HIV, AIDS or ARC?*
- Yes
- No
Have 2 or more of your parents, brothers or sisters been diagnosed with cancer, including Leukemia and Hodgkin's disease while they were under the age of 60?*
- Yes
- No
Have 2 or more of your parents, brothers or sisters been diagnosed with heart disease while they were under the age of 60?*
- Yes
- No
Consent
- I agree to the privacy policy

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Contact Us

#101 5015 50 Avenue
Camrose AB T4V 3P7
(780) 837 4355
info@supplementalinsurance.ca

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