Critical Illness

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Life, A&S, Health Provider	Assumption Life, Beneva, Blue Cross, BMO Life Assurance, Canada Protection Plan, Co-operators Life, Desjardins Financial Security Life, Empire Life, Equitable Life, FaithLife Financial, Foresters Canada, Great-West Life, Humania Assurance, Hunter McCorquodale Inc., Industrial Alliance, Ivari, La Capitale Life, London Life, Manulife Financial, Medavie Blue Cross, Primerica Life, RBC Insurance, Reliable Life, ScotiaLife, Specialty Life Insurance (SLI), SSQ Life, Standard Life Assurance, Sun Life Assurance, UV Insurance, Wawanesa Life
Province	Alberta, British Columbia, Manitoba, New Brunswick, Newfoundland & Labrador, Northwest Territories, Nova Scotia, Nunavut, Ontario, Prince Edward Island, Quebec, Saskatchewan, Yukon
Life, A&S, Health Products	Critical Illness

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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

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

Please select

Please select
Afghanistan
Albania
Algeria
American Samoa
Andorra
Angola
Anguilla
Antarctica
Antigua and Barbuda
Argentina
Armenia
Aruba
Australia
Austria
Azerbaijan
Bahamas
Bahrain
Bangladesh
Barbados
Belarus
Belgium
Belize
Benin
Bermuda
Bhutan
Bolivia
Bosnia and Herzegovina
Botswana
Brazil
Brunei
Bulgaria
Burkina Faso
Burundi
Cambodia
Cameroon
Canada
Cape Verde
Cayman Islands
Central African Republic
Chad
Chile
China
Colombia
Comoros
Congo
Costa Rica
Croatia
Cuba
Cyprus
Czech Republic
Denmark
Djibouti
Dominica
Dominican Republic
East Timor
Ecuador
Egypt
El Salvador
Equatorial Guinea
Eritrea
Estonia
Ethiopia
Fiji
Finland
France
French Guiana
French Polynesia
Gabon
Gambia
Georgia
Germany
Ghana
Gibraltar
Greece
Greenland
Grenada
Guam
Guatemala
Guinea
Guinea-Bissau
Guyana
Haiti
Honduras
Hong Kong
Hungary
Iceland
India
Indonesia
Iran
Iraq
Ireland
Israel
Italy
Jamaica
Japan
Jordan
Kazakhstan
Kenya
Kiribati
North Korea
South Korea
Kuwait
Kyrgyzstan
Laos
Latvia
Lebanon
Lesotho
Liberia
Libya
Liechtenstein
Lithuania
Luxembourg
Macedonia
Madagascar
Malawi
Malaysia
Maldives
Mali
Malta
Marshall Islands
Mauritania
Mauritius
Mexico
Micronesia
Moldova
Monaco
Mongolia
Montenegro
Montserrat
Morocco
Mozambique
Myanmar
Namibia
Nauru
Nepal
Netherlands
New Zealand
Nicaragua
Niger
Nigeria
Norway
Northern Mariana Islands
Oman
Pakistan
Palau
Palestine
Panama
Papua New Guinea
Paraguay
Peru
Philippines
Poland
Portugal
Puerto Rico
Qatar
Romania
Russia
Rwanda
Saint Kitts and Nevis
Saint Lucia
Saint Vincent and the Grenadines
Samoa
San Marino
Sao Tome and Principe
Saudi Arabia
Senegal
Serbia and Montenegro
Seychelles
Sierra Leone
Singapore
Slovakia
Slovenia
Solomon Islands
Somalia
South Africa
Spain
Sri Lanka
Sudan
Suriname
Swaziland
Sweden
Switzerland
Syria
Taiwan
Tajikistan
Tanzania
Thailand
Togo
Tonga
Trinidad and Tobago
Tunisia
Turkey
Turkmenistan
Tuvalu
Uganda
Ukraine
United Arab Emirates
United Kingdom
United States
Uruguay
Uzbekistan
Vanuatu
Vatican City
Venezuela
Vietnam
Virgin Islands, British
Virgin Islands, U.S.
Yemen
Zambia
Zimbabwe

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

Signature