Underwritten by

Applicants Information

Number of applicants * 

Amount Covered Before Departure

Age

Gender *

Date of Birth *

Last Name *

First Name *

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Insurance Start Date *

Travel Information

Duration of stay:

Insurance Expiry Date *

Destination *

Departure Province *

ELIGIBILITY (all applicants – all ages)

You are NOT eligible for coverage under this policy if:

a) you have been advised by a physician not to travel; and/or
b) you have been diagnosed with a terminal illness with less than 6 months to live; and/or
c) you have a kidney condition requiring dialysis; and/or
d) you have used home oxygen during the 12 months prior to the date of application

Email *

Contact Information

Phone (optional)

Are you eligible for the insurance policy?

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