Your First Name

Your Last Name

Phone Number for Quote Discussion *

Email *

What is the OLDEST insured person’s date of birth?

Ages of the other family members *

Sum Insured *

$10,000
$15,000
$25,000
$50,000
$100,000 (recommended)
$150,000
$200,000
$300,000
$500,000
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Start Date *

End Date *

Which province will the insured family be staying in?

Alberta
British Columbia
Manitoba
New Brunswick
Newfoundland and Labrador
Northwest Territories
Nova Scotia
Nunavut
Ontario
Prince Edward Island
Quebec
Saskatchewan
Yukon
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What type of insurance are you looking for? *

Lowest premium
Best value
Maximum coverage
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Does the insured person(s) have any pre-existing medical conditions? *

Yes

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.

Have any of the insureds been diagnosed with COVID-19 that required hospitalization, doctor visits, prescription medications or oxygen treatment? *

Yes

Since when the condition has been stable? *

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

Yes

Departure Date from the Home Country *

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

Yes

Notes: