To get a no-obligation quote for travel insurance, please complete the following form and submit it to our office. We will contact you within the next two business days. Please note that we can only provide insurance for residents of Ontario, Canada
You can add out-of-province emergency medical travel insurance to certain residential policies.
Your preferred means of communication for contact and follow-up :
E-mail
Phone
E-mail address :
Daytime telephone number :
Area 204 250 289 306 403 416 418 450 506 514 519 604 613 647 705 709 780 807 819 867 902 905 Ext. :
Home telephone number :
Area 204 250 289 306 403 416 418 450 506 514 519 604 613 647 705 709 780 807 819 867 902 905
Tell us about yourself...
Please Note : all fields must be completed for an accurate quote.
Name:
Address:
City:
Province:
Postal Code:
Sex
Male Female
Date of birth
(dd / mm / yyyy)
Health Card #
Do you want an annual plan?
Yes No
If yes, what is the maximum coverage period required for each trip?
30 days 60 days 90 days
Do you want a single trip plan?
If yes, how long will you be away?
Where will you be travelling? Do you want coverage for family members? Yes No If yes, please provide the name, relationship to you, sex, date of birth & Health Card # for each family member, travelling with you. Is anyone else travelling with you? Yes No If yes, please provide the name, relationship to you, sex, date of birth & Health Card # for anyone else travelling with you. Are you travelling for more than 35 days? Yes No If yes, do you or any member of your travelling family have any pre-existing medical conditions? Yes No If yes, our staff will be in touch with you to obtain the details.
Comment
Your Privacy You are authorizing that we collect, use or disclose your personal information contained on this information form as well as any additional information that we may obtain about you and other listed beneficiaries based on the information you have disclosed to us, (for example confirming your claims history or checking with motor vehicle agencies), for the purpose of providing you with this quote. By submitting this information form you also confirm that you have obtained the permission of all other potential beneficiaries listed on this information form for the collection, use and disclosure of their Personal Information for the purpose of providing you with this quote. Submission of this form does not constitute an application for insurance. Do you consent? Yes No
Thank you for taking the time to fill out this form. Select the "Submit" button below and we will contact you within the next two business days. Our quote will include the coverages you selected. We will include the cost of popular optional coverages with our quotation.
* Coverage is subject to the insurer's underwriting policies.
** To learn more about the protection of your personal information, consult Privacy & Legal.
