Health insurance covers up to $/var/www/srmrm.com/web/../cgi-bin/underwrite/perl-library/HMCVTC/RateChart/_202309.pl Max aggr.. Please read the policy before filling out the application.This product is underwritten by Industrial Alliance Insurance and Financial Services Inc.
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| What is your birth date?
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TRAVEL AND TRIP INFORMATION
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| Effective Date of this policy | |
| Termination Date of this policy | |
| OR Duration of coverage | days |
| Coverage Details: |
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Application Type?
Super Visa must be purchased for 365 days; a monthly billing option is available.
For shorter trips, select Visitor, Immigrant, Returning Canadian. |
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Note: Super Visa requires a single application for each party.
Note: This applies only if you are a student registered at a Canadian School. |
| Family, Couple or Single Coverage? |
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Note: Family denotes two adults plus dependants, Couple denotes two adults only.
The Birth Date of the eldest member must be used above. |
| Coverage: (Choose the desired limit) |
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| Country of origin or last residence: |
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| Allowances: |
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| Have you purchased a policy from us last year?
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| Is your travelling companion insured by us? (Receive a 5% allowance.)
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Companion's name: |
| Name of your Beneficiary:
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Relationship: |
| Notes |
| Please enter any additional, pertinent information and any other information relating to your health here: |
(500 characters) |
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PRE-EXISTING CONDITIONS ARE NOT COVERED WITH THIS APPLICATION.
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