Travel Insurance

First Name:

Last Name:

Address:

 Apt # 

City:

Province:

Postal Code:

Home Number:

Work Number:

 Ext: 

Fax Number:

E-mail:(optional)

Member of which association?

Association (if not listed above):

Marital status:

Choose Option:

Coverage for any new sickness or new injury only.
Coverage for pre-existing medicalconditions, along with coverage for any new sickness or newinjury

Departure date:

Return date:

Departure city:

Destination city:

Number of Days Coverage?:
(Standard number of days covered choices are: 2, 4, 8, 15, 30, 60, or 90 days.)

Any Unusual Activities?(If you will engage in unusual activities such as scuba diving, airplane flying, rock climbing, etc., list them here.)

This best describes my travelling situation:

 Visitor to Canada with Work Permit.

 Canadian Waiting for Provincial HealthInsurance

 Canadian Travelling Inside Canada

 Canadian travelling Outside Canada

 Visitor in Canada without Provincial HealthInsurance

 Health Travel Insurance Outside Canada (for Canadians)

Name of insured:

Date of birth:

Name of travel companion #1:

Companion #1 d.o.b.:

Name of travel companion #2:

Companion #2 d.o.b.:

Name of travel companion #3:

Companion #3 d.o.b.:

Name of travel companion #4:

Companion #4 d.o.b.:

Baggage & Peronal Effects Values:

Cost of Trip to be Covered?:

Amount of Life Ins. Desired?:

Any special Medical Coverage Desired?
(You may list dollar amount or type of medical coverage you want):

Reason for buying insurance:

Our office hours are 8:30am to 4:30pm EST Monday through Friday. Please advise when during these hours it would be most convenient to contact you?

If you would like to make any additional
comments, please enter them here.

Would you like to be added to our mailing list?

 Yes  No