Request Health Insurance Quote
Insured Information
Name of the Beneficiary / Policy Owner
*
First Name
Last Name
Phone Number
*
Format: (000) 000-0000.
Email
example@example.com
You must verify your email address before proceeding.
Your email address will not be sold or distributed.
Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
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Request Health Insurance Quote
Insured infomation
Name of the insured Person
First Name
Last Name
Date of Birth
*
/
Month
/
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Gender
Female
Male
Marital Status
Single
Married
Status
Visitor / Traveller Visa
PR without OHIP
Super Visa
Work Permit
Full-Time Student Visa
Other
Any depedent travelling with you in Canada during your stay?
Spouse
Children
Parents
If yes, what is their Name
First Name
Last Name
Your depedent's Date of Birth
-
Month
-
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
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Travel Plan
Your Arrival Date and Departure Date
Arrival Date
-
Month
-
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Effective Date
-
Month
-
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Coverage Departure Date
-
Month
-
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Do you have any travel plan leaving Canada for a few days?
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What is pre-existing condition?
Pre-Existing Medical Condition(s) means any medical condition, sickness or injury for which at any time prior to the effective date, you have experienced symptoms, you have received medical care, advice, investigation or medical treatment, you have been hospitalized, you have been prescribed (including prescribed as needed) or have taken medication, or you have undergone a medical surgical procedure.
Would you like to include pre-existing condition?
Yes please include Pre-existing condition coverage
No, please exclude Pre-existing condition coverage
Coverage Amount?
$50,000
$100,000 (mandatory for Super Visa Applicantion)
$150,000
$5,000,000 (avaliable for International full-time students or depedents)
Signature
Submit
Submit
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