Plan selection
Applicant information
Personal details
Medical information
Bank information

Plan selection

Which situation best describes you?

Select a plan

Blue Choice Conversion Plan (guaranteed!)

No medical questionnaire if you’ve had a workplace health and dental plan within the past 60 days. Includes comprehensive coverage for ambulance, dental, prescription drugs, vision and practitioner services. Also includes counselling services through our Individual Assistance Program.

Blue Choice Plan A

Includes basic coverage for ambulance, dental, prescription drugs and some practitioner services (e.g. physiotherapy, podiatry, chiropractic services). Medical questionnaire not required.

Blue Choice Plan B (most popular!)

Includes everything in Plan A, plus higher maximums and additional benefits for vision, travel within Canada and massage therapy. Also includes counselling services through our Individual Assistance Program. Medical questionnaire required.

Blue Choice Plan C (most robust!)

Includes everything in Plan A and Plan B, with higher maximums and additional coverage for orthodontics. Medical questionnaire required.

Accident

Includes coverage for ambulance, hospital, and accidental dental.

Retiree Basic

A comprehensive plan including coverage for ambulance, dental, prescription drugs and some practitioner services (e.g. physiotherapy, podiatry, chiropractic services). Travel coverage within Canada is included.

Retiree Standard (most robust!)

Our most robust retiree plan that includes international travel, plus everything in Retiree Basic with the added advantage of higher coverage maximums and additional coverage such as massage therapy, vision and hospital care.

Who needs coverage?

Applicant

Spouse/Common-law (optional)

Dependent (optional)

Contact information

Previous health benefits

The name of your previous health benefits provider (e.g. Alberta Blue Cross).
The unique number assigned to you by your previous health benefits provider, often listed on your coverage card.

Previous coverage

Drugs
Health
Dental

I understand that the personal information and personal health information provided herein as well as any other personal information and personal health information currently held or collected in the future by Manitoba Blue Cross and/or Blue Cross Life Insurance Company of Canada (collectively referred to as "Blue Cross") may be collected, used, or disclosed to administer the terms of the policy of which I am an eligible member, to develop and recommend suitable products and services to me, and to manage the company's business.

Depending on the type of coverage I carry, limited personal information or personal health information may be collected from and/or released to a third party. These include other Blue Cross organizations, licensed physicians and/or any other healthcare professionals or institutions, health and life insurers, government and regulatory authorities, and other third parties when required to administer the benefits outlined in the policy of which I am an eligible member. I understand that Blue Cross may retain service providers inside and outside of Canada to assist them in their business and further understand that my personal information may be subject to disclosure to law enforcement and other authorities, where required by law, both inside and outside of Canada, when such information is in the possession of Blue Cross or one of its authorized service providers.

I understand that I have provided my consent for Blue Cross to collect, use and disclose my personal information as outlined in the Blue Cross Privacy Code. I understand that I may revoke my consent at any time; however, if consent is withheld or revoked, the coverage may be denied or rescinded. I understand why my personal information and personal health information is needed and am aware of the risks and benefits of consenting or refusing to consent to its disclosure. For additional information regarding Blue Cross's privacy policies as to the collection, use, or disclosure of my information, I may contact Blue Cross at 204.775.0151 or 1.800.873.2583 or mb.bluecross.ca.

I authorize Blue Cross to collect, use and disclose my personal information and personal health information as described above.

Medical information

In order to complete this section, you'll need information about the following for all applicants:

  • Prescriptions or medications within the past 12 months and their approximate start dates
  • Diagnosed conditions, disorders, or illnesses and their approximate dates of diagnosis

Medical questionnaire

If you are unsure how to answer a question, you may leave it blank and an advisor will follow up with you.

Have you or any applicant(s) you've listed ever consulted a physician or medical practitioner, been treated for, or had any indication of the following?

Alcohol or drug abuse
Bone, joint or muscle disorder (e.g. arthritis, low bone density)
Cancer or tumour (e.g. leukemia, melanoma)
Chest pain, heart or circulatory disorder (e.g. blood clots, blocked arteries)
Diabetes or elevated blood sugar
High blood pressure
High cholesterol
Recurrent infections (e.g. cold sores, Herpes virus)
Skin disorder (e.g. psoriasis, acne, eczema)
Chronic headaches, migraines or dizziness
Neurological disorder (e.g. seizures, stroke/TIA, paralysis)
Gastrointestinal disorder (e.g. ulcers, GERD, Crohn's, colitis)
Kidney or urinary disorder (e.g. enlarged prostate, overactive bladder)
Liver disorder (e.g. Hepatitis, cirrhosis)
Reproductive or hormonal disorder (e.g. low testosterone, PCOS, fibroids)
Mental health or behavioral disorder (e.g. depression, anxiety, eating disorder, ADHD)
Respiratory/lung disorder or allergies (e.g. asthma, COPD, requires EpiPen)
AIDS, positive HIV test or other immunological disorder

Use this section to provide details for all Yes answers to the above questions.

Medical details

Family member
Height (ft./in.)
Weight (lb.)
Usual Physician or Medical Clinic (if none state "none")
John Smith

If you are unsure how to answer a question, you may leave it blank and an advisor will follow up with you.

Has an applicant above taken or been prescribed medication (e.g. pills, creams, eye drops, inhalers, patches) for any reason in the past 12 months?
Family member
Drug Name & Strength
Reason for Taking
Number of Refills per Year
Start Date
End Date
Does an applicant above have a condition, disease or disorder not listed previously?
Family member
Type of Disorder/Treatment
John Smith
Does an applicant above have an outstanding medical referral, test or investigation pending?
Family member
Reason for/Type of Investigation
Anticipated Date of Completion
John Smith
Does an applicant above have abnormal test results for which additional medical consultation has been advised?
Family member
Type of Investigation/Consultation
John Smith
Does an applicant above have undiagnosed signs and/or symptoms for which medical consultation is contemplated?
Family member
Type of Investigation/Consultation
John Smith

Bank information

Set up pre-authorized debit for easy premium payment.

(You will not be charged until your start date has been confirmed.)

Monthly pre-authorized debit

Success

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Having problems using this service? Contact us at 204.775.0151 or toll-free 1.888.596.1032