Application for travel insurance

Travel Insurance

Application for Travel Insurance

Applicant 1	First and last name Male Female
	Date of birth (dd/mmm/yyy)

Applicant 2	First and last name Male Female
	Date of birth (dd/mmm/yyy)

Applicant 3	First and last name Male Female
	Date of birth (dd/mmm/yyy)

Applicant 4	First and last name Male Female
	Date of birth (dd/mmm/yyy)
If there are more applicants, please put their names, gender, date of birth in the box Additional Information
Do you apply for Individual, Couple or Family Coverage?

Home address in Canada	Street Apt.
	City Province Postal Code
Telephone
E-mail

Province of Departure
Destination (Country or State in the USA)

Single-Trip Plans
Medical Insurance Trip Cancellation&Interruption Baggage Loss ⇛ Cost of Baggage All-Inclusive plan ⇛ Cost of Trip (for All-inclusive and Trip cancellation)

Departure Date	(dd/mmm/yyy)
Return Date	(dd/mmm/yyy)
For Top-up: Number of days covered by the existing policy

Multi-Trip (Annual) Plans
Medical Insurance Trip Cancellation&Interruption All-Inclusive ⇛ Cost of Trip (for All-inclusive and Trip cancellation)

Effective Date	(dd/mmm/yyy)
Number of days per trip

Coverage for Pre-existing Medical Conditions* is required * Pre-existing Medical Condition means injury, illness or disease; symptom(s) that exists before the effective date of insurance.

Additional Information

Please confirm your E-mail

Revised: November 10, 2011