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Plans
Extended health
Dental
Hospital
Travel
Premiums
Contact
Join now
Application for the Entente Group Insurance Program
Step
1
of
8
12%
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This field is for validation purposes and should be left unchanged.
Personal information
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PGA Application ID
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PGA member ID
Legal name
First
Last
Preferred communication language
English
French
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Personal email address
Enter Email
Confirm Email
Primary phone
(Required)
Alternate phone number
Date of birth DD/MM/YYYY
(Required)
DD slash MM slash YYYY
I have a government health plan (i.e. OHIP)
(Required)
Yes
No
Gender as shown on your province or territory health card
(Required)
Male
Female
X
Address
(Required)
Street Address
Address Line 2
City
Alberta
British Columbia
Manitoba
New Brunswick
Newfoundland and Labrador
Northwest Territories
Nova Scotia
Nunavut
Ontario
Prince Edward Island
Quebec
Saskatchewan
Yukon
Province
Postal Code
Health & insurance details
Select the best options regarding your current/previous insurance coverage
(Required)
I/my spouse/partner have/had extended health, dental and/or hospital coverage in the last 60 days
None. I have not been insured in the last 60 days with any plan(s)
Name of insurance company
Policy number
Identification number
Dental plan type
Single
Couple
Family
N/A
Extended health care plan type
Single
Couple
Family
N/A
Hospital & convalescent care plan type
Single
Couple
Family
N/A
Included in my extended health care plan
Dental plan termination date
DD slash MM slash YYYY
Extended health care plan termination date
DD slash MM slash YYYY
Hospital & convalescent care plan termination date
DD slash MM slash YYYY
Entente enrollment
Select the plans you’d like to enroll in (select all that apply):
(Required)
Extended health care plan
Dental care plan
Hospital & convalescent care plan
Select All
Extended health care plan
Extended health care plan type (Your spouse/partner or eligible dependent(s) can hold single coverage, even if you don’t join this plan.)
Plan members
(Required)
Single
Couple
Family
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Couple/family section
Does your spouse/partner have a valid province/territory health card?*
Yes
No
Spouse/partner name as shown on the province/territory health card
Spouse/partner gender as shown on the province/territory health card
Male
Female
X
Spouse/partner date of birth* (MM/DD/YYYY)
DD slash MM slash YYYY
Dependants
Dependent name as shown on the province/territory health card
Dependent gender as shown on the province/territory health card
Dependent date of birth*
Over 21?
If over 21: Student or functionally disabled
If student: Name of school
Add
Remove
Dental plan
Dental plan type (Your spouse/partner or eligible dependent(s) can hold single coverage, even if you don’t join this plan.)
Plan members
(Required)
Single
Couple
Family
This field is hidden when viewing the form
Couple/family section
Does your spouse/partner have a valid province/territory health card?*
Yes
No
Spouse/partner name as shown on the province/territory health card
Spouse/partner gender as shown on the province/territory health card
Male
Female
X
Spouse/partner date of birth* (MM/DD/YYYY)
DD slash MM slash YYYY
Dependents
Dependent name as shown on the province/territory health card
Dependent gender as shown on the province/territory health card
Dependent date of birth*
Over 21?
If over 21: Student or functionally disabled
If student: Name of school
Add
Remove
Hospital & convalescent care plan
Hospital plan type (Your spouse/partner or eligible dependent(s) can hold single coverage, even if you don’t join this plan.)
Plan members
(Required)
Single
Couple
Family
This field is hidden when viewing the form
Couple/family section
Does your spouse/partner have a valid province/territory health card?*
Yes
No
Spouse/partner name as shown on the province/territory health card
Spouse/partner gender as shown on the province/territory health card
Male
Female
X
Spouse/partner date of birth* (MM/DD/YYYY)
DD slash MM slash YYYY
Dependents
Dependent name as shown on the province/territory health card
Dependent gender as shown on the province/territory health card
Dependent date of birth*
Over 21?
If over 21: Student or functionally disabled
If student: Name of school
Add
Remove
Banking Information
For premium deduction authorization and direct deposit
Name of financial institution
(Required)
Branch address
(Required)
Street Address
Address Line 2
City
Alberta
British Columbia
Manitoba
New Brunswick
Newfoundland and Labrador
Northwest Territories
Nova Scotia
Nunavut
Ontario
Prince Edward Island
Quebec
Saskatchewan
Yukon
Province
Postal Code
Institution number (3 digits)
(Required)
Bank transit number (5 digits)
(Required)
Account number
(Required)
Full name on bank account
(Required)
First
Middle
Last
Coordination of benefits
Coordination of benefits may allow you to obtain a reimbursement of up to 100% of your eligible expenses.
Are you or any other family member entitled to medical benefits under any other plan?
Yes
No
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Name of insured family member
First
Middle
Last
Coverage
Single
Couple
Family
Type of coverage
Health
Dental
Hospital
Select All
Name of insurance company
Policy number
Identification number
