www.superstarinsurance.com

Superstar Investment Corp an authorized agent   for

Emergency Hospital & Medical Expense Coverage for:

International Students

 

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 Months Coverage      

 

                                             

 

 

Name of  Educational Institution attended in Canada

 

Education start Date                                                       

 

Expected Education Completion Date                         

 

 

Are you enrolled as a full time student        Yes        NO  

 

Coverage-     Single                No. of persons   

 

                        Family               No of persons   

 

 

 

 

 

 

Or Contact :

 

Superstar Investment Corp.

 

Telephone:

519-432-8700                                                                               

 FAX:

519-432-5445

 

Postal address:

25 Baseline Rd West. Suite 12  

        London Ontario,    Canada   N6J 1V1

Electronic mail:

General Information: superstarinsurance@superstarinvestment.com
Sales:                           superstarinvestments@rogers.com

 Internet :                                www.superstarinsurance.com    

                                                 www.superstarinvestment com