Insurance Application Form printable pdf download

ALL QUESTIONS MUST BE ANSWERED COMPLETELY. INDICATE “N/A” IF A QUESTION IS NOT APPLICABLE. IF THE SPACE PROVIDED IS

INSUFFICIENT TO ANSWER A QUESTION FULLY, PLEASE ATTACH A SEPARATE SHEET.

APPLICANT NAME: _______________________________________________________________________________________________________

MAILING ADDRESS: ______________________________________________________________________________________________________

CITY: ________________________________________________

PROVINCE: __________________

POSTAL CODE: __________________

PHONE: _________________________

CELL: _________________________

EMAIL: ____________________________________________

Please check the area(s) of complementary healthcare you are qualified to practice. If the modality is not shown, check ***other and explain below.

We also insure more than 101 other modalities. Visit

for the list.

Acupressure

CrossFit Certified

Iridology

Reflexology

Aromatherapy

Crystal Healing

Kinesiology

Reiki

Biofeedback

Energy Work

Nutritional Consulting

Shiatsu

Bowen Therapy

Esthetics *(see below)

Osteopathy

Thai Yoga Massage

Can-Fit Pro Certified

Healing Touch

Personal Trainer

Therapeutic Touch

Chair Massage

Hydrotherapy

Qi-Gong

Yoga/Pilates

Cranial Sacral

Ionization/Detox

Raindrop Therapy

Other Modalities ***

***Please provide details for other modalities not shown

above in this space

*If you have chosen Esthetics above, please list the

services you provide.

PREMIUMS INDICATED ARE ANNUAL PREMIUMS. Please choose

ONLY ONE

from this chart:

Standard PREM IUM: EVERY MODALITY EXCLUDING Shiatsu, Osteopathy and Kinesiology

$1,000,000 Limit

$225.00