Applicant's Name

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Applicant 2:

Applicant 3: 

Applicant  4:

Applicant 5:

Province of Residence

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

Country of Destination

   Individual Coverage       Family Coverage       Couple

Please Choose Your Plan

Single-Trip Medical Plan                      Multi-Trip (Annual) Medical Plan 

  Total Number of days  per trip *    

     * Single-Trip: Total trip length including departure and return days

       Multi-Trip : Max number of days per trip

For Top-up coverage:  number of days covered by the existing  policy   

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.

E-mail    

Phone       (if you want an insurance broker contact you)