Travel Questionnaire

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* 1. Contact Information

Name *

Company

Address *

Address 2

City/Town *

Province

Postal Code

Email Address *

Phone Number *

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

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* 2. Multi Trip Annual Travel Insurance

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* 3. Multi Trip Options

Multi trip worldwide

Multi trip within Canada

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* 4. Single Trip

Departure Date:

Date

Return Date:

Date

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* 5. Single Trip Options

Worldwide

Worldwide excluding USA (includes up to 5 days transit coverage in USA)

Within Canada

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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* 6. Who Is Travelling?

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* 7. Individual

Full Name:

Date of Birth:

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

1) Full Name:

Date of Birth:

2) Full Name:

Date of Birth:

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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)

1) Full Name:

Date of Birth:

2) Full Name:

Date of Birth:

3) Full Name:

Date of Birth:

4) Full Name:

Date of Birth:

5) Full Name:

Date of Birth:

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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?

Yes

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

Yes