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Universal Financial Strategies Inc

1 (877) 553-5678

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Health insurance covers up to $100,000. Please read the policy before filling out the application.


TRAVEL AND TRIP INFORMATION

What is your birth date?   (yyyy-mm-dd)
Effective Date of this policy (yyyy-mm-dd)
Termination Date of this policy (yyyy-mm-dd)
OR Duration of coverage days
Coverage details:    
Family, Couple or Single Coverage?
Family Couple Single
Note: Family denotes two adults plus dependants, Couple denotes two adults only. Add their names in the Note section below.
The Birth Date of the eldest member must be used above.
Application Type?
Super Visa
Student
Visitor, Immigrant, Returning Canadian
Note: Super Visa requires a single application for each party.
Coverage: (Choose the desired limit)
$10,000 $25,000 $50,000 $100,000 $150,000 $200,000
   
Country of origin:  
Allowances:    
Have you purchased a policy from us last year?
Yes No
 
Is your travelling companion insured by us? (Receive a 5% allowance.)
Yes No
Companion's name:

Notes 
Please enter any additional, pertinent information and any other information relating to your health here: (500 characters)

PRE-EXISTING CONDITIONS ARE NOT COVERED WITH THIS APPLICATION.