Applicants age 70 to 85 who wish to purchase "Stable Chronic Condition" option must complete the medical declaration (click to fill the form and print) on the application to determine eligibility for coverage. Please, contact our customer service toll free 1-866-920-2821 for more information.

Do you buy family plan:

Number of people to be insured:

1 2 3 4 5 6

First Name:

Last Name:

Gender:

male female

Date of Birth:

Arrival Date in Canada:

Country of Origin:

Visitors Type:

New Immigrant Returning Canadian Visitor Work or Student Visa Unknown

Address in Canada:

City:

Province:

Select province Alberta British Columbia Manitoba New Brunswick Newfoundland and Labrador Northwest Territories Nova Scotia Nunavut Ontario Prince Edward Island Quebec Saskatchewan Yukon Territory

Postal Code:

Phone:

E-mail:

Insurance Start Date:

Insurance End Date:

Insurance Benefit:

$10,000 $15,000 $25,000 $50,000 $100,000 $150,000

Sponsor Name:

Other Passengers:
First Name	Last Name	Gender	Date of Birth
		male female
		male female
		male female
		male female
		male female