Name

Applicant 1:  

Applicant 2:

Applicant 3: 

Applicant 4:

Applicant 5:

Province of Residence

Ontario Alberta British Columbia Manitoba New Brunswick Newfoundland Northwest Territories Nova Scotia Nunavut Prince Edward Island Quebec Saskatchewan Yukon

Country of Destination

Please choose your coverage:

Individual Coverage          Family Coverage                 Couple

Please choose your insurance plan

Single-Trip Medical Plan        (Emergency Medical insurance for one trip)

Top-up Emergency Medical for your existing travel medical plan

(You have already Medical plan (single trip or multi-trip) but you need coverage for more days)

Trip Cancellation/Interruption   → Cost of the trip (per person)  $

(This plan may be purchased with emergency medical plan or stand-alone)

Baggage Loss      →    Cost of the baggage (per person) $

(This plan may be purchased with emergency medical plan or stand-alone)

All-Inclusive   plan         →   Cost of the trip (per person)  $

(This plan includes Single-trip Emergency medical, Trip Cancellation/Interruption, Baggage Loss)

Annual Multi-Trip Medical Plan                     Annual Multi-Trip All-Inclusive Plan

(Emergency medical insurance for unlimited number of trips from your province of residence during one year. Click here for more information)

  Total Number of days  per trip *   

*  For Single-trip plans and top-ups: total trip length including departure and return days

    For Multi-trip plans: maximum number of days per trip

  For top-up: Number of days covered by the existing policy      

Coverage for  Pre-existing Medical Conditions*  is required      Please choose Yes No

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

E-mail              

 Phone                (if you want an insurance broker contact you)