Member Contact Information Form

Member Contact Information Form
Please complete the form below to receive plan information *required fields

Please supply me with a quotation/information on the following plan (check one or more):

1. Sun Life Financial Basic Health and Dental from $67.82 monthly

2. Sunlife Standard Plan from $97.81 monthly

3. Comprehensive Health Plans from PlanDirect from $113.82 monthly

Member Mailing Information:

*Name:

Address 1:

Address 2:

City:

Province:

(Select from list)

Postal Code:

Member Phone and E-mail Information:

*Telephone:

fax:

*e-mail:

*Date of Birth

(for cost comparison)

Questions or Comments:

What is the best time to contact you? (check one from each column)

Thank you!