Kiddy Plan Application Form

Make sure that you consult the Description of Coverage, including the procedure for filing a claim.

Yes, I would like to take advantage of the Kiddy Plan providing free critical
illness-children insurance for 12 months*. I understand that this offer does not involve any other obligation on my part. Please bring me my critical illness insurance-children policy, as well as the mini first aid kit included with the offer.

* Mandatory information
Your first name*
Your last name*
Civic no. and street*
Apartment no.
Post Office Box
City*
Province*
Postal code*
Telephone no.*	(  )  -
E-mail
How did you hear about the Kiddy plan?*     Specify:
Child's date of birth #1* (DD/MM/YYYY)	January February March April May June July August September October November December
Child's first name
Child's last name
Child's sex	Girl      Boy
Child's date of birth #2 (DD/MM/YYYY)	January February March April May June July August September October November December
Child's first name
Child's last name
Child's sex	Girl      Boy
Child's date of birth #3 (DD/MM/YYYY)	January February March April May June July August September October November December
Child's first name
Child's last name
Child's sex	Girl      Boy
Reserved for Administration only Agent code Agency code
You will receive your critical illness insurance for children and the mini first aid kit in four to six weeks.
This form is secure. For further information, consult the Confidentiality section.