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* 1. Contact Information

Please select either Multi Trip Annual Insurance  OR  Single Trip Insurance Options

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* 3. Multi Trip Options

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* 4. Single Trip

Departure Date:
Return Date:

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* 5. Single Trip Options

Please select either the Individual Medical Insurance  OR  Family Medical Insurance Option.

Family Medical Insurance can cover couples without dependents however they have to be either married or common law partners. Family medical coverage does not include adult family members who are not either married or common law partners.

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* 7. Individual

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* 8. Family - Adults (Up to age 59)

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* 9. Family - Dependents (Up to the age of 21 living at home or age 25 enrolled in school anywhere in the world)

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* 10. Address:

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* 11. Are you or any family member named above travelling against the advice of a doctor?

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* 12. Have you or any family member named above been diagnosed with a terminal condition?

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