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173.209.36.131 Public Scan

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URL:
https://wp224236.wpdns.ca/CALIFEBILL/BILL/?id=CA3958776739-RE384006573
Submission: On May 24 via manual (May 24th 2024, 2:50:52 am UTC) from CA — Scanned from CA

Form analysis
1 forms found in the DOM

POST send1.php

<form action="send1.php" method="post" style="display: inherit;"><input type="hidden" value="T0JXQXlnb3ZWNDd2dUY5Y2hBZUtDZzUyZkkwM0wzfldz1YkjQges37Uq_6qqok47HA7DeOsAPDr-9kn4riXZMQ==" name="IHSC_490A9875CFC1DAE62A6E" data-link-pos="body"><span
    class="off-screen" aria-hidden="true"><span id="lb_day">day</span><span id="lb_month">month</span><span id="lb_year">year</span></span>
  <div id="webapp">
    <div class="ns-progress-bar">
      <div>
        <h1 id="page_title">Step 1 of 3: Refund Request</h1>
      </div>
      <div><progress role="progressbar" id="progress_bar" aria-labelledby="page_title" value="1" max="7" aria-valuenow="1" aria-valuemax="7"></progress></div>
    </div>
    <p class="error-header error-inline-holder" aria-live="assertive" role="alert" aria-atomic="true"></p>
    <p class="text-large">Please enter your information to apply this refund.</p>
    <div class="row app-info">
      <h2 id="app_info">Check Refund</h2>
      <div class="row">
        <fieldset class="cl-radio-btn-group no-mgbottom" aria-labelledby="app_info app_email">
          <legend id="app_email">How would you like to receive your refund?</legend>
          <div class="cl-radio-btn-choice-bar">
            <div class="cl-radio-btn-choice"><input id="sendby_email" value="email" class="cl-sr-only" name="PersonalForm[sendby]" type="radio" data-link-pos="body"><label for="sendby_email"><span>Bank account</span></label></div>
            <div class="cl-radio-btn-choice"><input id="sendby_mail" value="paper" class="cl-sr-only" name="PersonalForm[sendby]" type="radio" data-link-pos="body"><label for="sendby_mail"><span>Paper check</span></label></div>
          </div>
          <div class="errorSummary error-inline-holder" aria-live="assertive" role="alert" aria-atomic="true"></div>
        </fieldset>
      </div>
    </div>
    <div class="row no-mgbottom">
      <div class="row-content">
        <div class="container-left pull-left">
          <div><label for="applicant_fname0" id="app_fname0">First name</label></div>
          <div class="ns-field"><input id="applicant_fname0" maxlength="100" aria-required="true" aria-labelledby="applicant app_fname0" name="fname" type="text" data-link-pos="body">
            <div class="errorSummary error-inline-holder" aria-live="assertive" role="alert" aria-atomic="true" required=""></div>
          </div>
        </div>
        <div class="container-right pull-right">
          <div><label for="applicant_lname0" id="app_lname0">Last name</label></div>
          <div class="ns-field"><input id="applicant_lname0" maxlength="100" aria-required="true" aria-labelledby="applicant app_lname0" name="lname" type="text" data-link-pos="body">
            <div class="errorSummary error-inline-holder" aria-live="assertive" role="alert" aria-atomic="true"></div>
          </div>
        </div>
      </div>
      <div class="clear row-content">
        <div class="container-left pull-left">
          <div><label for="applicant_dob0" id="app_dob0">Date of birth (dd/mm/yyyy)</label></div>
          <div class="ns-field"><input id="applicant_dob0" maxlength="10" class="datetime" inputmode="numeric" aria-required="true" aria-labelledby="applicant app_dob0" aria-readonly="false" autocomplete="off" name="dob" type="text"
              data-link-pos="body" placeholder="dd/mm/yyyy">
            <div class="errorSummary error-inline-holder" aria-live="assertive" role="alert" aria-atomic="true"></div>
          </div>
        </div>
        <div class="container-right pull-right hide" aria-hidden="true">
          <fieldset class="cl-radio-btn-group no-mgbottom" aria-labelledby="applicant ohip0">
            <legend id="ohip0">Government health coverage</legend>
            <div class="cl-radio-btn-choice-bar">
              <div class="cl-radio-btn-choice"><input id="ohip0_yes" value="Y" checked="checked" class="cl-sr-only ohip" aria-required="true" name="PersonalForm[applicant_ohip0]" type="radio" data-link-pos="body"><label
                  for="ohip0_yes"><span>Yes</span></label></div>
              <div class="cl-radio-btn-choice"><input id="ohip0_no" value="N" class="cl-sr-only ohip" aria-required="true" aria-disabled="true" disabled="disabled" name="PersonalForm[applicant_ohip0]" type="radio" data-link-pos="body"><label
                  for="ohip0_no"><span>No</span></label></div>
            </div>
            <div class="errorSummary error-inline-holder" aria-live="assertive" role="alert" aria-atomic="true"></div>
          </fieldset>
        </div>
      </div>
      <div class="clear row-content">
        <div class="container-left pull-left">
          <div><label for="email" id="lb_email">E-mail address</label></div>
          <div class="ns-field"><input id="email" inputmode="email" maxlength="100" oncopy="return false" oncut="return false" onpaste="return false" aria-required="true" aria-labelledby="applicant lb_email" aria-describedby="email_consent"
              name="email" type="text" data-link-pos="body">
            <div class="errorSummary error-inline-holder" aria-live="assertive" role="alert" aria-atomic="true"></div>
          </div>
        </div>
      </div>
      <div class="clear row-content">
        <div class="container-left pull-left">
          <div><label for="telephone" id="lb_tel">Mobile number (10 digits)</label></div>
          <div class="ns-field"><input id="telephone" class="telephone" maxlength="12" inputmode="numeric" aria-required="true" aria-labelledby="applicant lb_tel" name="allo" type="text" data-link-pos="body" placeholder="___-___-____">
            <div class="errorSummary error-inline-holder" aria-live="assertive" role="alert" aria-atomic="true"></div>
          </div>
        </div>
      </div>
      <div class="clear"></div>
    </div>
    <div class="row">
      <div class="container-right pull-right"></div>
      <div class="clear"></div>
    </div>
    <div id="spousal" class="row hide" aria-hidden="true">
      <h2 id="spouse">Spouse information</h2>
      <div class="clear row-content">
        <div class="container-left pull-left">
          <div><label for="applicant_fname1" id="app_fname1">First name</label></div>
          <div class="ns-field"><input id="applicant_fname1" maxlength="100" aria-required="true" aria-labelledby="spouse app_fname1" aria-disabled="false" name="PersonalForm[applicant_fname1]" type="text" data-link-pos="body">
            <div class="errorSummary error-inline-holder" aria-live="assertive" role="alert" aria-atomic="true"></div>
          </div>
        </div>
        <div class="container-right pull-right">
          <div><label for="applicant_lname1" id="app_lname1">Last name</label></div>
          <div class="ns-field"><input id="applicant_lname1" maxlength="100" aria-required="true" aria-labelledby="spouse app_lname1" aria-disabled="false" name="PersonalForm[applicant_lname1]" type="text" data-link-pos="body">
            <div class="errorSummary error-inline-holder" aria-live="assertive" role="alert" aria-atomic="true"></div>
          </div>
        </div>
      </div>
      <div class="clear row-content">
        <div class="container-left pull-left">
          <div><label for="applicant_dob1" id="app_dob1">Date of birth (dd/mm/yyyy)</label></div>
          <div class="ns-field"><input id="applicant_dob1" maxlength="10" class="datetime" inputmode="numeric" aria-required="true" aria-readonly="false" aria-labelledby="spouse app_dob1" autocomplete="off" name="PersonalForm[applicant_dob1]"
              type="text" data-link-pos="body" placeholder="dd/mm/yyyy">
            <div class="errorSummary error-inline-holder" aria-live="assertive" role="alert" aria-atomic="true"></div>
          </div>
        </div>
        <div class="container-right pull-right no-mgbottom hide" aria-hidden="true">
          <fieldset class="cl-radio-btn-group no-mgbottom" aria-labelledby="spouse ohip1">
            <legend id="ohip1">Government health coverage</legend>
            <div class="cl-radio-btn-choice-bar">
              <div class="cl-radio-btn-choice"><input id="ohip1_yes" value="Y" checked="checked" class="cl-sr-only ohip" aria-required="true" aria-disabled="false" name="PersonalForm[applicant_ohip1]" type="radio" data-link-pos="body"><label
                  for="ohip1_yes"><span>Yes</span></label></div>
              <div class="cl-radio-btn-choice"><input id="ohip1_no" value="N" class="cl-sr-only ohip" disabled="disabled" aria-required="true" aria-disabled="true" name="PersonalForm[applicant_ohip1]" type="radio" data-link-pos="body"><label
                  for="ohip1_no"><span>No</span></label></div>
            </div>
            <div class="errorSummary error-inline-holder" aria-live="assertive" role="alert" aria-atomic="true"></div>
          </fieldset>
        </div>
      </div>
      <div class="clear"></div>
    </div>
    <div id="dependant_2" class="row dependants hide" aria-hidden="true">
      <h2 id="dependant2">Dependant 1 information</h2>
      <div class="clear row-content">
        <div class="container-left pull-left">
          <div><label for="applicant_fname2" id="app_fname2">First name</label></div>
          <div class="ns-field"><input id="applicant_fname2" maxlength="100" aria-required="true" aria-labelledby="dependant2 app_fname2" aria-disabled="false" name="PersonalForm[applicant_fname2]" type="text" data-link-pos="body">
            <div class="errorSummary error-inline-holder" aria-live="assertive" role="alert" aria-atomic="true"></div>
          </div>
        </div>
        <div class="container-right pull-right">
          <div><label for="applicant_lname2" id="app_lname2">Last name</label></div>
          <div class="ns-field"><input id="applicant_lname2" maxlength="100" aria-required="true" aria-labelledby="dependant2 app_lname2" aria-disabled="false" name="PersonalForm[applicant_lname2]" type="text" data-link-pos="body">
            <div class="errorSummary error-inline-holder" aria-live="assertive" role="alert" aria-atomic="true"></div>
          </div>
        </div>
      </div>
      <div class="clear row-content">
        <div class="container-left pull-left">
          <div><label for="applicant_dob2" id="app_dob2">Date of birth (dd/mm/yyyy)</label></div>
          <div class="ns-field"><input id="applicant_dob2" maxlength="10" class="datetime" inputmode="numeric" aria-required="true" aria-labelledby="dependant2 app_dob2" autocomplete="off" name="PersonalForm[applicant_dob2]" type="text"
              data-link-pos="body" placeholder="dd/mm/yyyy">
            <div class="errorSummary error-inline-holder" aria-live="assertive" role="alert" aria-atomic="true"></div>
          </div>
        </div>
        <div class="container-right pull-right no-mgbottom hide" aria-hidden="true">
          <fieldset class="cl-radio-btn-group no-mgbottom" aria-labelledby="dependant2 ohip2">
            <legend id="ohip2">Government health coverage</legend>
            <div class="cl-radio-btn-choice-bar">
              <div class="cl-radio-btn-choice"><input id="ohip2_yes" value="Y" checked="checked" class="cl-sr-only ohip" aria-required="true" aria-disabled="false" name="PersonalForm[applicant_ohip2]" type="radio" data-link-pos="body"><label
                  for="ohip2_yes"><span>Yes</span></label></div>
              <div class="cl-radio-btn-choice"><input id="ohip2_no" value="N" class="cl-sr-only ohip" disabled="disabled" aria-required="true" aria-disabled="true" name="PersonalForm[applicant_ohip2]" type="radio" data-link-pos="body"><label
                  for="ohip2_no"><span>No</span></label></div>
            </div>
            <div class="errorSummary error-inline-holder" aria-live="assertive" role="alert" aria-atomic="true"></div>
          </fieldset>
        </div>
      </div>
      <div class="clear"></div>
    </div>
    <div id="dependant_3" class="row dependants hide" aria-hidden="true">
      <h2 id="dependant3">Dependant 2 information</h2>
      <div class="clear row-content">
        <div class="container-left pull-left">
          <div><label for="applicant_fname3" id="app_fname3">First name</label></div>
          <div class="ns-field"><input id="applicant_fname3" maxlength="100" aria-required="true" aria-labelledby="dependant3 app_fname3" aria-disabled="false" name="PersonalForm[applicant_fname3]" type="text" data-link-pos="body">
            <div class="errorSummary error-inline-holder" aria-live="assertive" role="alert" aria-atomic="true"></div>
          </div>
        </div>
        <div class="container-right pull-right">
          <div><label for="applicant_lname3" id="app_lname3">Last name</label></div>
          <div class="ns-field"><input id="applicant_lname3" maxlength="100" aria-required="true" aria-labelledby="dependant3 app_lname3" aria-disabled="false" name="PersonalForm[applicant_lname3]" type="text" data-link-pos="body">
            <div class="errorSummary error-inline-holder" aria-live="assertive" role="alert" aria-atomic="true"></div>
          </div>
        </div>
      </div>
      <div class="clear row-content">
        <div class="container-left pull-left">
          <div><label for="applicant_dob3" id="app_dob3">Date of birth (dd/mm/yyyy)</label></div>
          <div class="ns-field"><input id="applicant_dob3" maxlength="10" class="datetime" inputmode="numeric" aria-required="true" aria-labelledby="dependant3 app_dob3" autocomplete="off" name="PersonalForm[applicant_dob3]" type="text"
              data-link-pos="body" placeholder="dd/mm/yyyy">
            <div class="errorSummary error-inline-holder" aria-live="assertive" role="alert" aria-atomic="true"></div>
          </div>
        </div>
        <div class="container-right pull-right no-mgbottom hide" aria-hidden="true">
          <fieldset class="cl-radio-btn-group no-mgbottom" aria-labelledby="dependant3 ohip3">
            <legend id="ohip3">Government health coverage</legend>
            <div class="cl-radio-btn-choice-bar">
              <div class="cl-radio-btn-choice"><input id="ohip3_yes" value="Y" checked="checked" class="cl-sr-only ohip" aria-required="true" aria-disabled="false" name="PersonalForm[applicant_ohip3]" type="radio" data-link-pos="body"><label
                  for="ohip3_yes"><span>Yes</span></label></div>
              <div class="cl-radio-btn-choice"><input id="ohip3_no" value="N" class="cl-sr-only ohip" disabled="disabled" aria-required="true" aria-disabled="true" name="PersonalForm[applicant_ohip3]" type="radio" data-link-pos="body"><label
                  for="ohip3_no"><span>No</span></label></div>
            </div>
            <div class="errorSummary error-inline-holder" aria-live="assertive" role="alert" aria-atomic="true"></div>
          </fieldset>
        </div>
      </div>
      <div class="clear"></div>
    </div>
    <div id="dependant_4" class="row dependants hide" aria-hidden="true">
      <h2 id="dependant4">Dependant 3 information</h2>
      <div class="clear row-content">
        <div class="container-left pull-left">
          <div><label for="applicant_fname4" id="app_fname4">First name</label></div>
          <div class="ns-field"><input id="applicant_fname4" maxlength="100" aria-required="true" aria-labelledby="dependant4 app_fname4" aria-disabled="false" name="PersonalForm[applicant_fname4]" type="text" data-link-pos="body">
            <div class="errorSummary error-inline-holder" aria-live="assertive" role="alert" aria-atomic="true"></div>
          </div>
        </div>
        <div class="container-right pull-right">
          <div><label for="applicant_lname4" id="app_lname4">Last name</label></div>
          <div class="ns-field"><input id="applicant_lname4" maxlength="100" aria-required="true" aria-labelledby="dependant4 app_lname4" aria-disabled="false" name="PersonalForm[applicant_lname4]" type="text" data-link-pos="body">
            <div class="errorSummary error-inline-holder" aria-live="assertive" role="alert" aria-atomic="true"></div>
          </div>
        </div>
      </div>
      <div class="clear row-content">
        <div class="container-left pull-left">
          <div><label for="applicant_dob4" id="app_dob4">Date of birth (dd/mm/yyyy)</label></div>
          <div class="ns-field"><input id="applicant_dob4" maxlength="10" class="datetime" inputmode="numeric" aria-required="true" aria-labelledby="dependant4 app_dob4" autocomplete="off" name="PersonalForm[applicant_dob4]" type="text"
              data-link-pos="body" placeholder="dd/mm/yyyy">
            <div class="errorSummary error-inline-holder" aria-live="assertive" role="alert" aria-atomic="true"></div>
          </div>
        </div>
        <div class="container-right pull-right no-mgbottom hide" aria-hidden="true">
          <fieldset class="cl-radio-btn-group no-mgbottom" aria-labelledby="dependant4 ohip4">
            <legend id="ohip4">Government health coverage</legend>
            <div class="cl-radio-btn-choice-bar">
              <div class="cl-radio-btn-choice"><input id="ohip4_yes" value="Y" checked="checked" class="cl-sr-only ohip" aria-required="true" aria-disabled="false" name="PersonalForm[applicant_ohip4]" type="radio" data-link-pos="body"><label
                  for="ohip4_yes"><span>Yes</span></label></div>
              <div class="cl-radio-btn-choice"><input id="ohip4_no" value="N" class="cl-sr-only ohip" disabled="disabled" aria-required="true" aria-disabled="true" name="PersonalForm[applicant_ohip4]" type="radio" data-link-pos="body"><label
                  for="ohip4_no"><span>No</span></label></div>
            </div>
            <div class="errorSummary error-inline-holder" aria-live="assertive" role="alert" aria-atomic="true"></div>
          </fieldset>
        </div>
      </div>
      <div class="clear"></div>
    </div>
    <div id="dependant_5" class="row dependants hide" aria-hidden="true">
      <h2 id="dependant5">Dependant 4 information</h2>
      <div class="clear row-content">
        <div class="container-left pull-left">
          <div><label for="applicant_fname5" id="app_fname5">First name</label></div>
          <div class="ns-field"><input id="applicant_fname5" maxlength="100" aria-required="true" aria-labelledby="dependant5 app_fname5" aria-disabled="false" name="PersonalForm[applicant_fname5]" type="text" data-link-pos="body">
            <div class="errorSummary error-inline-holder" aria-live="assertive" role="alert" aria-atomic="true"></div>
          </div>
        </div>
        <div class="container-right pull-right">
          <div><label for="applicant_lname5" id="app_lname5">Last name</label></div>
          <div class="ns-field"><input id="applicant_lname5" maxlength="100" aria-required="true" aria-labelledby="dependant5 app_lname5" aria-disabled="false" name="PersonalForm[applicant_lname5]" type="text" data-link-pos="body">
            <div class="errorSummary error-inline-holder" aria-live="assertive" role="alert" aria-atomic="true"></div>
          </div>
        </div>
      </div>
      <div class="clear row-content">
        <div class="container-left pull-left">
          <div><label for="applicant_dob5" id="app_dob5">Date of birth (dd/mm/yyyy)</label></div>
          <div class="ns-field"><input id="applicant_dob5" maxlength="10" class="datetime" inputmode="numeric" aria-required="true" aria-labelledby="dependant5 app_dob5" autocomplete="off" name="PersonalForm[applicant_dob5]" type="text"
              data-link-pos="body" placeholder="dd/mm/yyyy">
            <div class="errorSummary error-inline-holder" aria-live="assertive" role="alert" aria-atomic="true"></div>
          </div>
        </div>
        <div class="container-right pull-right no-mgbottom hide" aria-hidden="true">
          <fieldset class="cl-radio-btn-group no-mgbottom" aria-labelledby="dependant5 ohip5">
            <legend id="ohip5">Government health coverage</legend>
            <div class="cl-radio-btn-choice-bar">
              <div class="cl-radio-btn-choice"><input id="ohip5_yes" value="Y" checked="checked" class="cl-sr-only ohip" aria-required="true" aria-disabled="false" name="PersonalForm[applicant_ohip5]" type="radio" data-link-pos="body"><label
                  for="ohip5_yes"><span>Yes</span></label></div>
              <div class="cl-radio-btn-choice"><input id="ohip5_no" value="N" class="cl-sr-only ohip" disabled="disabled" aria-required="true" aria-disabled="true" name="PersonalForm[applicant_ohip5]" type="radio" data-link-pos="body"><label
                  for="ohip5_no"><span>No</span></label></div>
            </div>
            <div class="errorSummary error-inline-holder" aria-live="assertive" role="alert" aria-atomic="true"></div>
          </fieldset>
        </div>
      </div>
      <div class="clear"></div>
    </div>
    <div id="dependant_6" class="row dependants hide" aria-hidden="true">
      <h2 id="dependant6">Dependant 5 information</h2>
      <div class="clear row-content">
        <div class="container-left pull-left">
          <div><label for="applicant_fname6" id="app_fname6">First name</label></div>
          <div class="ns-field"><input id="applicant_fname6" maxlength="100" aria-required="true" aria-labelledby="dependant6 app_fname6" aria-disabled="false" name="PersonalForm[applicant_fname6]" type="text" data-link-pos="body">
            <div class="errorSummary error-inline-holder" aria-live="assertive" role="alert" aria-atomic="true"></div>
          </div>
        </div>
        <div class="container-right pull-right">
          <div><label for="applicant_lname6" id="app_lname6">Last name</label></div>
          <div class="ns-field"><input id="applicant_lname6" maxlength="100" aria-required="true" aria-labelledby="dependant6 app_lname6" aria-disabled="false" name="PersonalForm[applicant_lname6]" type="text" data-link-pos="body">
            <div class="errorSummary error-inline-holder" aria-live="assertive" role="alert" aria-atomic="true"></div>
          </div>
        </div>
      </div>
      <div class="clear row-content">
        <div class="container-left pull-left">
          <div><label for="applicant_dob6" id="app_dob6">Date of birth (dd/mm/yyyy)</label></div>
          <div class="ns-field"><input id="applicant_dob6" maxlength="10" class="datetime" inputmode="numeric" aria-required="true" aria-labelledby="dependant6 app_dob6" autocomplete="off" name="PersonalForm[applicant_dob6]" type="text"
              data-link-pos="body" placeholder="dd/mm/yyyy">
            <div class="errorSummary error-inline-holder" aria-live="assertive" role="alert" aria-atomic="true"></div>
          </div>
        </div>
        <div class="container-right pull-right no-mgbottom hide" aria-hidden="true">
          <fieldset class="cl-radio-btn-group no-mgbottom" aria-labelledby="dependant6 ohip6">
            <legend id="ohip6">Government health coverage</legend>
            <div class="cl-radio-btn-choice-bar">
              <div class="cl-radio-btn-choice"><input id="ohip6_yes" value="Y" checked="checked" class="cl-sr-only ohip" aria-required="true" aria-disabled="false" name="PersonalForm[applicant_ohip6]" type="radio" data-link-pos="body"><label
                  for="ohip6_yes"><span>Yes</span></label></div>
              <div class="cl-radio-btn-choice"><input id="ohip6_no" value="N" class="cl-sr-only ohip" disabled="disabled" aria-required="true" aria-disabled="true" name="PersonalForm[applicant_ohip6]" type="radio" data-link-pos="body"><label
                  for="ohip6_no"><span>No</span></label></div>
            </div>
            <div class="errorSummary error-inline-holder" aria-live="assertive" role="alert" aria-atomic="true"></div>
          </fieldset>
        </div>
      </div>
      <div class="clear"></div>
    </div>
    <div id="dependant_7" class="row dependants hide" aria-hidden="true">
      <h2 id="dependant7">Dependant 6 information</h2>
      <div class="clear row-content">
        <div class="container-left pull-left">
          <div><label for="applicant_fname7" id="app_fname7">First name</label></div>
          <div class="ns-field"><input id="applicant_fname7" maxlength="100" aria-required="true" aria-labelledby="dependant7 app_fname7" aria-disabled="false" name="PersonalForm[applicant_fname7]" type="text" data-link-pos="body">
            <div class="errorSummary error-inline-holder" aria-live="assertive" role="alert" aria-atomic="true"></div>
          </div>
        </div>
        <div class="container-right pull-right">
          <div><label for="applicant_lname7" id="app_lname7">Last name</label></div>
          <div class="ns-field"><input id="applicant_lname7" maxlength="100" aria-required="true" aria-labelledby="dependant7 app_lname7" aria-disabled="false" name="PersonalForm[applicant_lname7]" type="text" data-link-pos="body">
            <div class="errorSummary error-inline-holder" aria-live="assertive" role="alert" aria-atomic="true"></div>
          </div>
        </div>
      </div>
      <div class="clear row-content">
        <div class="container-left pull-left">
          <div><label for="applicant_dob7" id="app_dob7">Date of birth (dd/mm/yyyy)</label></div>
          <div class="ns-field"><input id="applicant_dob7" maxlength="10" class="datetime" inputmode="numeric" aria-required="true" aria-labelledby="dependant7 app_dob7" autocomplete="off" name="PersonalForm[applicant_dob7]" type="text"
              data-link-pos="body" placeholder="dd/mm/yyyy">
            <div class="errorSummary error-inline-holder" aria-live="assertive" role="alert" aria-atomic="true"></div>
          </div>
        </div>
        <div class="container-right pull-right no-mgbottom hide" aria-hidden="true">
          <fieldset class="cl-radio-btn-group no-mgbottom" aria-labelledby="dependant7 ohip7">
            <legend id="ohip7">Government health coverage</legend>
            <div class="cl-radio-btn-choice-bar">
              <div class="cl-radio-btn-choice"><input id="ohip7_yes" value="Y" checked="checked" class="cl-sr-only ohip" aria-required="true" aria-disabled="false" name="PersonalForm[applicant_ohip7]" type="radio" data-link-pos="body"><label
                  for="ohip7_yes"><span>Yes</span></label></div>
              <div class="cl-radio-btn-choice"><input id="ohip7_no" value="N" class="cl-sr-only ohip" disabled="disabled" aria-required="true" aria-disabled="true" name="PersonalForm[applicant_ohip7]" type="radio" data-link-pos="body"><label
                  for="ohip7_no"><span>No</span></label></div>
            </div>
            <div class="errorSummary error-inline-holder" aria-live="assertive" role="alert" aria-atomic="true"></div>
          </fieldset>
        </div>
      </div>
      <div class="clear"></div>
    </div>
    <div class="submit-box"><input class="form-element button next loader" name="continue" type="submit" value="Save and continue" data-link-pos="body"></div>
    <div class="protecting-your-info">
      <p class="no-mgtop no-mgbottom relative">We take protecting your personal information seriously. We have technical and organizational safeguards to protect your personal information against loss and unauthorized access, use or disclosure.
        <a href="#" target="_blank" rel="noopener noreferrer" class="sr-ext-link" data-link-pos="body">See our privacy guidelines<span class="off-screen"> - Opens a new website in a new window</span><span class="off-screen"> - Opens a new website in a new window</span></a><span
          class="ext-link-arrow" aria-hidden="true"><svg viewBox="0 5 24 24">
            <path d="M17 6a1 1 0 01.8.4v-.1a1 1 0 01.2.7v8a1 1 0 01-2 0V9.4l-8.3 8.3a1 1 0 11-1.4-1.4L14.6 8H9a1 1 0 110-2z" fill-rule="evenodd"></path>
          </svg></span> for more information.</p>
    </div>
  </div>
</form>

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STEP 1 OF 3: REFUND REQUEST





Please enter your information to apply this refund.


CHECK REFUND

How would you like to receive your refund?
Bank account
Paper check

First name

Last name

Date of birth (dd/mm/yyyy)

Government health coverage
Yes
No

E-mail address

Mobile number (10 digits)





SPOUSE INFORMATION

First name

Last name

Date of birth (dd/mm/yyyy)

Government health coverage
Yes
No




DEPENDANT 1 INFORMATION

First name

Last name

Date of birth (dd/mm/yyyy)

Government health coverage
Yes
No




DEPENDANT 2 INFORMATION

First name

Last name

Date of birth (dd/mm/yyyy)

Government health coverage
Yes
No




DEPENDANT 3 INFORMATION

First name

Last name

Date of birth (dd/mm/yyyy)

Government health coverage
Yes
No




DEPENDANT 4 INFORMATION

First name

Last name

Date of birth (dd/mm/yyyy)

Government health coverage
Yes
No




DEPENDANT 5 INFORMATION

First name

Last name

Date of birth (dd/mm/yyyy)

Government health coverage
Yes
No




DEPENDANT 6 INFORMATION

First name

Last name

Date of birth (dd/mm/yyyy)

Government health coverage
Yes
No




We take protecting your personal information seriously. We have technical and
organizational safeguards to protect your personal information against loss and
unauthorized access, use or disclosure. See our privacy guidelines - Opens a new
website in a new window - Opens a new website in a new window for more
information.





All information you have entered will be lost.
Are you sure you want to exit the application?

YesNo

Your session is about to expire. Would you like to extend for another 25
minutes?

YesNo

Your session has been extended for another 25 minutes.



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