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       Date of Entry into Canada

Coverage Selection

Emergency Hospital & Medical options

                                        $10,000       25,000      $50,000    $100,000    $150,000

Family Coverage           Yes         No

Deductible Option          $100 (5%savings)        $250 ( 10%savings)

Flight Accident                $200,000                      $500,000 

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