Applicant Information

           First Name                           Last Name                           Date of Birth               Email Address                    Country

    Address in Canada                        City/Province                                   Postal Code                      Tel Number

   Effective Date                                Expiry Date                                      No of Days of Coverage      Departure Point

Destination                 Departure Date

ALL-Inclusive Package Plan

     USA Package Plan                  Non-USA Package Plan        Youth Adventure Plan 

       After departure sum insured  $25,000            Enter Prior to  Departure  Sum Insured

Optional Plans

    Baggage                    $   1,000            $  1,500     

    AD& D                       $ 25,000           $200,000         $250,000   

    Flight Accident           $200,000           $500,000  

    Trip Interruption           $     800               $ 1,500        $   2,000  

    Rental Car Collision     $ 50,000