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

Coverage Selection

Emergency Hospital & Medical options

        USA Plan                NON-USA Plan                     Sports Plan        

Multi Trip Plan      Trip Days      8        15           60         105

         Basic Plan              Select Plan     Option 1      Option 2  

Trip Cancellation & Interruption          Basic Plan        Select Plan 

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

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