Applicant 1:   

First Name       

Applicant 2:    

First Name      

Applicant 3: 

First Name  

Last Name        

Last Name    

Last Name   

Date o Birth   

           (dd/mmm/yyyy)

Date o Birth             

                    (dd/mmm/yyyy)

Date o Birth 

                  (dd/mmm/yyyy)

Gender:     Male    Female

Gender:     Male        Female

Gender: Male        Female

 I am          Please choose An International Student studying in Canada A Canadian Student studying abroad A National Student studying outside Ontario

  Individual Coverage         Family Coverage        Couple

Effective Date (dd/mmm/yyyy)        (Example: 10/Oct/09)

Expiry Date   (dd/mmm/yyyy)      

Address in Canada :   Street    Apt.

                               City            Province            Postal Code                 

School Name    

Coverage for  Pre-existing  Medical Conditions *      Please choose Required Not Required  

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

Tel.                   Best Time to Call  (Toronto time)  

E-mail