Prism Precision Application

Prism Precision® Application

Thank you for applying to the Prism Precision Program
Thank you for applying to the Prism Precision program. This program is geared towards individuals who are looking for a cost effective program for basic services not covered by the provincial government. Some of these plans offer minimal prescription drug and dental coverage while others offer a comprehensive dental plan with no prescription coverage. This program is a guaranteed program so you cannot be declined. Please make sure you fill out all information boxes and read and check all checkboxes in order to apply successfully.

We require your agreement with the terms of purchase.
Please read the terms carefully before you proceed and indicate your agreement by clicking the box below. If you do not agree with these terms, please exit the site. *

I/We have read and agree with terms of purchase

SECTION C | Mailing Information (Step 3 of 7)
Same as applicant?

Yes
Last Name *
First Name *
Middle Name
Street Address *
Apt. No
City/Town *
Province / Territory *
Postal Code *
Enter letters in Uppercase
Copied Province
Main(Cell) Phone *
Please enter a valid phone number.
Business Phone
Please enter a valid phone number.
Email *
example@example.com
What is your preferred method of contact? *

Main (cell) Telephone Email Business Phone
Family Status *

Single Couple Family Other
Applicant's Occupation

Section D - Statement of Health (Step 4 of 7)
NOTE: Questions 1 and 2 on this page have similar child questions, but question 3 deals with
pregnancy and has slightly different fields.
Have you, your spouse/partner or any listed dependent children been hospitalized in the last two (2) years? *

YES NO
*
Do you, your spouse/partner or any listed dependent children expect to be hospitalized in the next six (6) months? *

YES NO
*
Are you, your spouse/partner or any listed dependent children pregnant? *

YES NO
*

Section E - Dental Information (Step 5 of 7)
Do you, your spouse/partner and/or any listed dependent children plan to visit a dentist in the next three (3) months? *

YES NO
If “YES”, please indicate dental work to be done *
NOTE: If the proposed dental work is expected to exceed $300 a detailed treatment plan is required from your dentist before your treatment begins

SECTION I | Declarations and Authorizations (Step 7 of 7)
NOTE: The information provided on this form is confidential

Terms & Conditions
Terms & Conditions *

I/We agree that the statements contained herein are true and complete, to the best of my/our knowledge and form the basis for any coverage approved. I am authorized to release information concerning my spouse/partner and my dependent children, for the purposes of determining their eligibility for benefits.
*

I/We understand that failure to disclose or falsifying information regarding my health and/or that of my spouse/partner and/or dependent children could result in denial of a claim and the cancellation or modification of this coverage.
*

I/We understand that it is my/our obligation to inform Special Benefits Insurance Services Agency Inc. of a change in my health and that of my spouse/partner and any listed dependent children due to either injury or illness which occurs after the date of application and prior to the effective date of the policy.
*

I/We understand that the coverage shall not become effective until the first (1st) of the month following approval by or on behalf of Green Shield Canada. I/We authorize any physician, dentist, medical practitioner, hospital, clinic or other medical or medical related facility, insurance company, or other organization, institution or person that has any records or knowledge of my health, and that of my spouse/partner and any listed dependent children, to exchange any such information as is needed to administer benefit claims and/or to confirm the accuracy of the information with Special Benefits Insurance Services Agency Inc. and/or Green Shield Canada. A reproduction of this consent and authorization shall be as valid as the original.
*

I/We acknowledge that Special Benefits Insurance Services is the distributor for this program and receives a commission from GSC. If you have any questions about this program or our compensation, please call us at 1-800-667-0429. By no means does this commission influence which plans we offer. Each offering is unique and is based on the individual's needs and budget.
*

I/We understand that by checking this box the name(s) entered below constitute a legal and binding signature(s) confirming that I/We acknowledge and agree to the above terms for the purpose of applying.
Name of Applicant *
Date

Year Month Day
Name of Spouse/Partner (required if applying for coverage)
Date

Year Month Day
COVERAGE PROVIDED BY GREEN SHIELD CANADA
Green Shield Canada’s commitment to privacy. Your personal information is collected for the purpose of providing you with health and dental benefits, claims analysis and payments. For information on Green Shield Canada’s privacy policies and procedures, visit greenshield.ca
Additional Information Form

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Prism Precision® Application

SECTION A: Coverage Information (Step 1 of 7)

SECTION B | Individuals to be Covered (Step 2 of 7)

SECTION C | Mailing Information (Step 3 of 7)

Section D - Statement of Health (Step 4 of 7)

Section E - Dental Information (Step 5 of 7)

SECTION F- Payment Information (Step 6 of 7)

SECTION I | Declarations and Authorizations (Step 7 of 7)

COVERAGE PROVIDED BY GREEN SHIELD CANADA