Welcome! - Pacific Cross

Welcome, Valued Client!

Before we proceed with updating your information, please provide the following for validation purposes:

NOTE: Fields marked with an asterisk (*) are mandatory

First Name *

Middle Name

Last Name *

Birth Date*

Email Address *

I understand that by answering this form, I am updating my existing personal information as a Policyholder/Member of Pacific Cross Insurance, Inc. and/or Pacific Cross Health Care, Inc. in compliance with the regulatory requirement of the Anti-Money Laundering Act (AMLA) and in accordance with the Data Privacy Act (DPA) of 2012, and that all information provided in this Client Information Update Form is true and correct.