Apply Online

Wondering what Quikcard can do for you? Use our online template to design a custom plan that caters to your needs. Remember, if you have any questions, please don’t hesitate to contact us.

Assessment Form

Please use the form below to create a custom plan to meet your needs. You can start from scratch or use the templates to assist in building your custom plan.

Plan Template:

Plan Details

Number Of Families

Number Of Singles

For a complete evaluation, please provide us with the details of your existing plan as well as any changes you need to make. All numbers reflect the coverage per person.

Plan Design	Existing Plan	Proposed Plan
Dental (%)
Deductable
Basic Services (i.e. Exams/Fillings, etc) (%)
Major Services (i.e. Crowns/Dentures, etc) (%)
Orthodontic Coverage (%)
Annual Maximums ($)
Vision (%)
Annual Maximums ($)
Health Services (psychological services, audiology, acupuncture, massage therapy, physiotherapy, pharmaceuticals, medical services and equipment, other services and supplies on Medical Doctor's referral.
Health Service Coverage (%)
Annual Maximums ($)
Employee & Family Assistance Program (%)
Annual Maximums ($)
Drug Card (%)
Annual Maximums ($)

Proposed Plan - Summary

To enable an accurate funding analysis, please supply as much information as you can regarding your claims experience, work in progress, or proposed treatment in the box below. Please also place any additional questions or comments below.

Your Contact Information

* Company Name:
* Contact Title:
* First Name:
* Last Name:
* Address:
* City:
* Province:
* Postal Code:		A9A 9A9
* Area Code & Phone Number:		(999) 999-9999
Area Code & Fax Number:		(999) 999-9999
Proposed Effective Date:		DD/MM/YY
* Email:
How did you hear about us?