Information Order Form

Company Name*
Attention*	Job Title*
Address*	Suite	City/Town*
Province*	Postal Code*
Phone*	Ext Email *Required Field
# of Employees	Under 10 10 to 50 51 to 250 Over 250
Current Group Health Provider

Quantity

Health and Dental Program Brochures

This brochure provides a basic overview of the Green Shield Canada Prism^® health and dental programs that
are available, plus contact information that employees can use to apply or obtain additional information.

Quantity

Health and Dental Program Enrollment Packages

Each package contains an introductory letter, application forms, current rate sheets and brochures that
outline the coverage available with the different Green Shield Canada Prism^® health and dental programs.

NOTE: We ship 1-2 business days once we receive your completed request. If you have any special circumstances please indicate them below or contact our office at 1-800-667-0429 to discuss.