Extended Health Benefits Application

(Includes Seniors)

Applicant Information

Surname Given Name(s)
Birthdate (d/m/y) HCP # (Health Care Number)
Mailing Address
______
Home Phone e-mail Address

Employment Status

Description

/

Applicant - Demandeur

/

Common-Law / Spouse - Conjoint

Are you Employed? / Yes No / Yes No
If Yes, Name of Employer or Government Department. / /
Employer’s Phone number. / /
Do you have an Insurance Plan? / Yes No
Oui Non / Yes No
Oui Non
If Yes, Name of Plan. / /

See over

Medical Statement (To be completed by physician or community health nurse)

I here by certify that the information given is true, correct and complete to the best of my knowledge.
Signature: ______Date: ______
(Applicant, Parent, or Guardian)

Applicant’s Declaration

Employer Statement - To be completed if checked “no” for insurance coverage, disregard if retired

I certify that ______has not opted out of any insurance plan offered through
(name of applicant)
employment and that ______does not currently cover any costs towards medical travel,
(name of employer)
airfare, accommodation, meals and/or ground transportation .
______
Signature (Employer) and Job Title Date
______
Phone Number
See over for 2nd job information

Return Completed Application to: Nunavut Health Insurance Programs (NHIP) For Office Use Only

Department of Health  Create File

Box 889  Add to Manual List

Rankin Inlet, NU X0C 0G0  Letter

See over

Does your insurance plan cover any of the following?

1. A group medical insurance plan.Yes No

If yes, please indicate plan name______

2. A prescription drug planYes No

If yes, please indicate level of coverage______

3. Travel costs for medical reasons Yes No

If yes, does this include meals & accommodation?______

4. Ambulance costs Yes No

If yes, please indicate level of coverage______

5. Dental Benefits Yes No

If yes, please indicate level of coverage______

6. Eyeglass Benefits Yes No

If yes, please indicate level of coverage______

7. Medical Equipment / Supplies

If yes, please indicate level of coverage______

8. A retirement group insurance plan

If yes, please indicate level of coverage & benefits and start date of retirement benefits

______

9. Is the employee’s spouse & dependents entitled to any benefits? Yes No

If yes, please indicate which benefits______

Medications (include DIN)To be filled out by Physician or Nurse

2ndEmployer Statement - To be completed if checked “no” for insurance coverage, disregard if retired

I certify that ______has not opted out of any insurance plan offered through
(name of applicant)
employment and that ______does not currently cover any costs towards medical travel,
(name of employer)
airfare, accommodation, meals and/or ground transportation .
______
Signature (Employer) and Job Title Date
______
Phone Number

Phone 867-645-8001 Toll Free 1-800-661-0833 Fax 867-645-8092 e-mail: