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Visitor to Canada

Download application or submit online

Underwriting Requirement

Optional Coverages

Personal Info:

Coverage For

Pre Existing Medical Condition

Pre Existing Medical Condition
Non Pre Existing Medical Condition

Province*

Alberta

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

Number of Traveller

1

1
2
3
4
5
6

Date of Birth

Policy Effective Date

Policy Expiry Date

Coverage Amount*

5000

5000
10000
15000
20000
25000

Deductible*

0

0
100
200
250
300
500
1000
1500
2000
2500
3000
5000
7500
10000

Home/Origin Country

Accident and Dismemberment

0

0
5000
10000
15000

Baggage Loss

0

0
5000
10000
15000

Car Rental

0

0
5000
10000
15000

Flight Delay

0

0
5000
10000
15000

Trip Cancellation & Interruption

0

0
5000
10000
15000

Flight Accident

0

0
5000
10000
15000

Accident & Dismemberment

5000

5000
10000
15000
20000

Choose Amount limit

Baggage Lost

5000

5000
10000
15000
20000

Car Rental (per day & maximum limit)

25 / 500

25 / 500
30 / 600
35 / 650
40 / 700

Choose Amount limit

Flight Delay

5000

5000
10000
15000
20000

Choose Amount limit

Trip Cancellation & Interruption

5000

5000
10000
15000
20000

Choose Amount limit

Flight Accident

5000

5000
10000
15000
20000

Choose Amount limit

Applicant/Insured

First Name

Middle Name

Last Name

Applicant/Insured 2

First Name

Middle Name

Last Name

Applicant/Insured 3

First Name

Middle Name

Last Name

Applicant/Insured 4

First Name

Middle Name

Last Name

Applicant/Insured 5

First Name

Middle Name

Last Name

Applicant/Insured 6

First Name

Middle Name

Last Name

Address Line 1

Address Line 2

City

Province

Alberta

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

Zip/Postal Code

Phone

Email

Signature

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