The MAI Application Form

Please enter your information below. Our application process typically takes between one and two business days. If you have any questions or problems with this application, please don't hesitate to call us at 1-866-416-2259. Alternatively, you may complete our paper form.

Applicant Information

Name First:

Last:

Initial(s):

Date of Birth

Gender Male Female

Phone Day:

Evening:

Email Address

Mailing Address

City

Province

Postal Code

Check this if billing name or address differs from the information above.

Coverage Selection

Do you have provincial health plan coverage? Yes No

Are you a business owner or sole proprietor? Yes No

Are you applying for spousal coverage? Yes No

Number of dependent children to cover:

Applying for Maternity Benefits? Yes No

Expected due date:

Information About Spouse

Spouse's Name First:

Last:

Birth Date

Gender Male Female

Provincial Health Plan Coverage? Yes No

1^st Dependent

Dependent's Name First:

Last:

Birth Date

Gender Male Female

Relationship to applicant

Provincial Health Plan Coverage? Yes No

To qualify for dependent coverage after reaching the age of 19, your dependent must be:

Single (neither married nor living in a common-law relationship);
Financially supported by you or your spouse;
Under the age of 25;
Attending school or university full-time;

OR

Incapable of supporting themselves due to a mental or physical disability;

Which of the above requirements applies to the dependent listed?
Full-time student Mentally/physically disabled Neither (not eligible for coverage)

Name and address of school

Expected graduation date

Note: You will need to mail proof of enrolment upon completion of this form.

Note: You will be required to mail a report or letter from the dependent's personal physician confirming the diagnosis and prognosis for the dependent, and the extent to which the physician determines the dependent is unable to work.

2^nd Dependent

Dependent's Name First:

Last:

Birth Date

Gender Male Female

Relationship to applicant

Provincial Health Plan Coverage? Yes No

To qualify for dependent coverage after reaching the age of 19, your dependent must be:

Single (neither married nor living in a common-law relationship);
Financially supported by you or your spouse;
Under the age of 25;
Attending school or university full-time;

OR

Incapable of supporting themselves due to a mental or physical disability;

Which of the above requirements applies to the dependent listed?
Full-time student Mentally/physically disabled Neither (not eligible for coverage)

Name and address of school

Expected graduation date

Note: You will need to mail proof of enrolment upon completion of this form.

Note: You will be required to mail a report or letter from the dependent's personal physician confirming the diagnosis and prognosis for the dependent, and the extent to which the physician determines the dependent is unable to work.

3^rd Dependent

Dependent's Name First:

Last:

Birth Date

Gender Male Female

Relationship to applicant

Provincial Health Plan Coverage? Yes No

To qualify for dependent coverage after reaching the age of 19, your dependent must be:

Single (neither married nor living in a common-law relationship);
Financially supported by you or your spouse;
Under the age of 25;
Attending school or university full-time;

OR

Incapable of supporting themselves due to a mental or physical disability;

Which of the above requirements applies to the dependent listed?
Full-time student Mentally/physically disabled Neither (not eligible for coverage)

Name and address of school

Expected graduation date

Note: You will need to mail proof of enrolment upon completion of this form.

Note: You will be required to mail a report or letter from the dependent's personal physician confirming the diagnosis and prognosis for the dependent, and the extent to which the physician determines the dependent is unable to work.

4^th Dependent

Dependent's Name First:

Last:

Birth Date

Gender Male Female

Relationship to applicant

Provincial Health Plan Coverage? Yes No

To qualify for dependent coverage after reaching the age of 19, your dependent must be:

Single (neither married nor living in a common-law relationship);
Financially supported by you or your spouse;
Under the age of 25;
Attending school or university full-time;

OR

Incapable of supporting themselves due to a mental or physical disability;

Which of the above requirements applies to the dependent listed?
Full-time student Mentally/physically disabled Neither (not eligible for coverage)

Name and address of school

Expected graduation date

Note: You will need to mail proof of enrolment upon completion of this form.

Note: You will be required to mail a report or letter from the dependent's personal physician confirming the diagnosis and prognosis for the dependent, and the extent to which the physician determines the dependent is unable to work.

5^th Dependent

Dependent's Name First:

Last:

Birth Date

Gender Male Female

Relationship to applicant

Provincial Health Plan Coverage? Yes No

To qualify for dependent coverage after reaching the age of 19, your dependent must be:

Single (neither married nor living in a common-law relationship);
Financially supported by you or your spouse;
Under the age of 25;
Attending school or university full-time;

OR

Incapable of supporting themselves due to a mental or physical disability;

Which of the above requirements applies to the dependent listed?
Full-time student Mentally/physically disabled Neither (not eligible for coverage)

Name and address of school

Expected graduation date

Note: You will need to mail proof of enrolment upon completion of this form.

Note: You will be required to mail a report or letter from the dependent's personal physician confirming the diagnosis and prognosis for the dependent, and the extent to which the physician determines the dependent is unable to work.

6^th Dependent

Dependent's Name First:

Last:

Birth Date

Gender Male Female

Relationship to applicant

Provincial Health Plan Coverage? Yes No

To qualify for dependent coverage after reaching the age of 19, your dependent must be:

Single (neither married nor living in a common-law relationship);
Financially supported by you or your spouse;
Under the age of 25;
Attending school or university full-time;

OR

Incapable of supporting themselves due to a mental or physical disability;

Which of the above requirements applies to the dependent listed?
Full-time student Mentally/physically disabled Neither (not eligible for coverage)

Name and address of school

Expected graduation date

Note: You will need to mail proof of enrolment upon completion of this form.

Note: You will be required to mail a report or letter from the dependent's personal physician confirming the diagnosis and prognosis for the dependent, and the extent to which the physician determines the dependent is unable to work.

7^th Dependent

Dependent's Name First:

Last:

Birth Date

Gender Male Female

Relationship to applicant

Provincial Health Plan Coverage? Yes No

To qualify for dependent coverage after reaching the age of 19, your dependent must be:

Single (neither married nor living in a common-law relationship);
Financially supported by you or your spouse;
Under the age of 25;
Attending school or university full-time;

OR

Incapable of supporting themselves due to a mental or physical disability;

Which of the above requirements applies to the dependent listed?
Full-time student Mentally/physically disabled Neither (not eligible for coverage)

Name and address of school

Expected graduation date

Note: You will need to mail proof of enrolment upon completion of this form.

Note: You will be required to mail a report or letter from the dependent's personal physician confirming the diagnosis and prognosis for the dependent, and the extent to which the physician determines the dependent is unable to work.

8^th Dependent

Dependent's Name First:

Last:

Birth Date

Gender Male Female

Relationship to applicant

Provincial Health Plan Coverage? Yes No

To qualify for dependent coverage after reaching the age of 19, your dependent must be:

Single (neither married nor living in a common-law relationship);
Financially supported by you or your spouse;
Under the age of 25;
Attending school or university full-time;

OR

Incapable of supporting themselves due to a mental or physical disability;

Which of the above requirements applies to the dependent listed?
Full-time student Mentally/physically disabled Neither (not eligible for coverage)

Name and address of school

Expected graduation date

Note: You will need to mail proof of enrolment upon completion of this form.

Note: You will be required to mail a report or letter from the dependent's personal physician confirming the diagnosis and prognosis for the dependent, and the extent to which the physician determines the dependent is unable to work.

9^th Dependent

Dependent's Name First:

Last:

Birth Date

Gender Male Female

Relationship to applicant

Provincial Health Plan Coverage? Yes No

To qualify for dependent coverage after reaching the age of 19, your dependent must be:

Single (neither married nor living in a common-law relationship);
Financially supported by you or your spouse;
Under the age of 25;
Attending school or university full-time;

OR

Incapable of supporting themselves due to a mental or physical disability;

Which of the above requirements applies to the dependent listed?
Full-time student Mentally/physically disabled Neither (not eligible for coverage)

Name and address of school

Expected graduation date

Note: You will need to mail proof of enrolment upon completion of this form.

Note: You will be required to mail a report or letter from the dependent's personal physician confirming the diagnosis and prognosis for the dependent, and the extent to which the physician determines the dependent is unable to work.

10^th Dependent

Dependent's Name First:

Last:

Birth Date

Gender Male Female

Relationship to applicant

Provincial Health Plan Coverage? Yes No

To qualify for dependent coverage after reaching the age of 19, your dependent must be:

Single (neither married nor living in a common-law relationship);
Financially supported by you or your spouse;
Under the age of 25;
Attending school or university full-time;

OR

Incapable of supporting themselves due to a mental or physical disability;

Which of the above requirements applies to the dependent listed?
Full-time student Mentally/physically disabled Neither (not eligible for coverage)

Name and address of school

Expected graduation date

Note: You will need to mail proof of enrolment upon completion of this form.

Note: You will be required to mail a report or letter from the dependent's personal physician confirming the diagnosis and prognosis for the dependent, and the extent to which the physician determines the dependent is unable to work.

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