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Applicants Information:

First Name *

Date of Birth *

Gender *

Age

Amount Covered Before Departure

Travel Information:

Insurance Start Date:*

Insurance Expiry Date:*

Duration of stay:

Departure Province *

Destination *

ELIGIBILITY (all applicants – all ages)

You are NOT eligible for coverage under this policy if:

a) you have been advised by a physician not to travel; and/or
b) you have been diagnosed with a terminal illness with less than 6 months to live; and/or
c) you have a kidney condition requiring dialysis; and/or
d) you have used home oxygen during the 12 months prior to the date of application

 

Are you eligible for the insurance policy?
 

Last Name *

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