Applicant(s) Information:

Age

Gender *

Date of Birth *

Last Name *

Given Name(s) *

Underwritten by

Number of applicant(s) * 

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Travel Information:

Insurance Expiry Date *

Insurance Start Date *

Duration of stay

Canada Arrival Date *

Visitor Type *

Destination *

Country of Origin *

Email *

Contact Information:

Phone:

ELIGIBILITY (all applicant(s) – all ages)

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You are NOT eligible for coverage under this policy if:

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• you are travelling against the advice of a physician,

• you have been diagnosed with a terminal illness with less than two (2) years to live,

• you have been diagnosed with or received treatment within the last two (2) years for pancreatic, lung, brain, or liver cancer; or any type of cancer that has spread from one part or organ of the body to another (metastatic cancer),

• you have had or are waiting for an organ or bone marrow transplant (excluding corneal transplant),

• you have a kidney condition requiring dialysis,

• you have used home oxygen during the 12 months prior to the date of application,

• you reside in a nursing home, other long term care facility or rehabilitation centre.

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Are you eligible for the insurance policy?