Please be advised that a Super Visa insurance requires a minimum of $100,000 worth of coverage for at least 365 days.

Arrival Date in Canada *

Partial refunds may be available for early departure, subject to insurance policy terms. Please provide the estimated departure date for an accurate quote.

Departure Date from Canada *

Which province will the insured persons be staying in?

What type of insurance are you looking for? *

First Applicant

What is the first applicant’s date of birth?

Does the first applicant have any pre-existing medical conditions? *

Yes

No

Please, list the pre-existing conditions *

How long have these conditions been stable? *

Stability in policy wordings is defined as: There have been no new symptoms or change in symptoms and/or there has been no hospitalization or change in treatment, medication or dosage prior to the effective date.

Has the first applicant been diagnosed with COVID-19 that required hospitalization, doctor visits, prescription medications or oxygen treatment? *

Yes

No

Since when the condition has been stable? *

Second Applicant

What is the second applicant’s date of birth?

Does the second applicant have any pre-existing medical conditions *

Yes

No

Please list the pre-existing conditions *

How long have these conditions been stable? *

Stability in policy wordings is defined as: There have been no new symptoms or change in symptoms and/or there has been no hospitalization or change in treatment, medication or dosage prior to the effective date

Has the second applicant been diagnosed with COVID-19 that required hospitalization, doctor visits, prescription medications or oxygen treatment *

Yes

No

Since when the condition has been stable? *

Would you like to have coverage on the flight for medical emergencies? *

Yes

No

Departure Date from the Home Country *

Do you plan to make any side trips before, during or after your visit to Canada? *

Yes

No

Notes: