travel application

Important reason to disclose all medical history. Read More

Booking times for additional Travel Insurance. Read More

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Please follow the instructions carefully in each section

BEGIN APPLICATION HERE

Reason for Travel *Personal / BusinessOther

This policy does not cover:

participation in any professional athletics
participation in acrobatics or stunt flying, mountaineering, hand gliding, scuba diving, any racing or speed contests

View Travel Booklet

You are seeing this message because you chose "Other" for Reason for Travel and / or this policy has certain coverage limitations as outlined in the policy booklet, Travel Booklet. Therefore, you cannot submit this application. Contact us if you require further assistance.

DATES OF TRAVEL

Estimated Departure Date: *

Estimated Return Date: *

APPLICANTS INFORMATION

First Name *

Last Name *

Date of Birth:

Month

Day *

Year *

Age *

Gender *MaleFemale

Age:

PRIMARY RESIDENCE

Street Address *

City *

Province *

Postal Code *

Phone *

E-mail Address

Travel - Medical Questions Required for Travel Coverage (Applicant)

The following medical questions are required for all travelers covered on this travel policy aged 70+. Medical questions help us to determine your eligibility and premium rate.

Pre-existing conditions are based on Age of the Traveler(s)

Pre-existing conditions could affect your coverage if the answer to any of the medical questions are 'YES', up to the date of departure for your trip(s). Medical question help us to determine your eligibility and premium rate.

If the answer to any of the medical questions are 'YES' than a conversation with Arlene Marko, of our Travel Team is required.

1) Have you received medical advice, consultations, or treatment within 6 months (age 70-80) prior to the date of departure of a trip out of your home province? *YesNo

Details:

2) Have you received a prescription or a change (up or down) to an existing prescription within 6 months (age 70-80) of the date of departure of a trip out of your home province? *YesNo

Details:

3) Do you have a diagnosis for a chronic condition for a disease or disorder which has existed for a minimum of 6 months (age 70-80) prior to the date of departure of a trip out of your home province? *YesNo

Details:

4) Have you ever been treated for any form of heart condition or stroke for a minimum of 6 months (age 70-80) prior to the date of departure of a trip out of your home province? *YesNo

5) Has your doctor given any indication of any risk because of your health not to travel 6 months (age 70-80) prior to date of departure of a trip? *YesNo

Details:

Date of last visit to doctor? *

Exclusions and Limitations

** any condition for which the Insured Person received medical advice, consultation or treatment within six (6) months prior to the commencement of a Trip, with the exception of a Chronic Condition which is under treatment and Stabilized by the regular use of prescribed medication.

"Chronic Condition" means a disease or disorder which has existed for a minimum of six (6) months.

"Stabilized" means there has not been a change in the medical condition requiring medical or psychiatric intervention for a minimum of six (6) months, adjustments in doses of Warfarin or Coumadin are not considered to be medical intervention for the purpose of this definition.

SPOUSE INFORMATION

Do You Have A Spouse? *YesNo

First Name *

Last Name *

Date of Birth:

Month

Day *

Year *

Age *

Age:

Gender *MaleFemale

Travel - Medical Questions Required for Travel Coverage (Spouse)

The following medical questions are required for all travelers covered on this travel policy aged 70+. Medical question help us to determine your eligibility and premium rate.

Pre-existing conditions are based on Age of the Traveler(s)

Pre-existing conditions could affect your coverage if the answer to any of the medical questions are 'YES', up to the date of departure for your trip(s). Medical questions help us to determine your eligibility and premium rate.

If the answer to any of the medical questions are 'YES' than a conversation with Arlene Marko, of our Travel Team is required.

1) Have you received medical advice, consultations, or treatment within 6 months (age 70-80) prior to the date of departure of a trip out of your home province? *YesNo

Details:

2) Have you received a prescription or a change (up or down) to an existing prescription within 6 months (age 70-80) of the date of departure of a trip out of your home province? *YesNo

Details:

4) Have you ever been treated for any form of heart condition or stroke for a minimum of 6 months (age 70-80) prior to the date of departure of a trip out of your home province? *YesNo

5) Has your doctor given any indication of any risk because of your health not to travel 6 months (age 70-80) prior to date of departure of a trip? *YesNo

Details:

Date of last visit to doctor? *

Exclusions and Limitations

"Chronic Condition" means a disease or disorder which has existed for a minimum of six (6) months.

CHILDREN & DEPENDENTS

Do You Have Dependents Traveling on this Trip? *YesNo

Select DependentsChildrenElderly Parent(s)

Children

First & Last Name

Birthdate

Elderly Parent(s)

First & Last Name

Birthdate

Age

Parent #2

First & Last Name

Birthdate

Age

Travel - Medical Questions Required for Travel Coverage (Dependent)

The following medical questions are required for all travelers covered on this travel policy aged 70+. Medical question help us to determine your eligibility and premium rate.

Pre-existing conditions are based on Age of the Traveler(s)

If the answer to any of the medical questions are 'YES' than a conversation with Arlene Marko, of our Travel Team is required.

1) Have you received medical advice, consultations, or treatment within 6 months (age 70-80) prior to the date of departure of a trip out of your home province? *YesNo

Details:

2) Have you received a prescription or a change (up or down) to an existing prescription within 6 months (age 70-80) of the date of departure of a trip out of your home province? *YesNo

Details:

4) Have you ever been treated for any form of heart condition or stroke for a minimum of 6 months (age 70-80) prior to the date of departure of a trip out of your home province? *YesNo

5) Has your doctor given any indication of any risk because of your health not to travel 6 months (age 70-80) prior to date of departure of a trip? *YesNo

Details:

Date of last visit to doctor? *

Second Dependent Medical Questions

1) Have you received medical advice, consultations, or treatment within 6 months (age 70-80) prior to the date of departure of a trip out of your home province? *YesNo

Details:

2) Have you received a prescription or a change (up or down) to an existing prescription within 6 months (age 70-80) of the date of departure of a trip out of your home province? *YesNo

Details:

4) Have you ever been treated for any form of heart condition or stroke for a minimum of 6 months (age 70-80) prior to the date of departure of a trip out of your home province? *YesNo

5) Has your doctor given any indication of any risk because of your health not to travel 6 months (age 70-80) prior to date of departure of a trip? *YesNo

Details:

Date of last visit to doctor? *

Exclusions and Limitations

"Chronic Condition" means a disease or disorder which has existed for a minimum of six (6) months.

ADDITIONAL INFORMATION

Are you a Business Owner? *YesNo

Company Name:

Are you Retired? *YesNo

Were you referred to us? *YesNo

Name of Referrer

*The following 3 questions are subject to additional charges outside of this Travel Application.

If you answered 'Yes' to any of the question we will contact you with product information and pricing.

*Do you require Travel Interruption Protection? *YesNo

*Do you require Trip Cancelation Protection? *YesNo

*Do you require Kidnap & Ransom Insurance? *YesNo

TRAVEL INSURANCE PRICING

SELECT LENGTH OF TRIP

30 Day Travel Pricing for Two or more people - Selection must be made based on oldest person on this APPLICATION. *60 to 64 | $305.0065 to 69 | $455.0070 to 74 | $560.0075 to 80 | $975.00

60 Day Travel Pricing for Two or more people - Selection must be made based on oldest person on this APPLICATION. *60 to 64 | Family | $535.0065 to 69 | Family | $780.0070 to 74 | Family | $955.0075 to 80 | Family | $1665.00

90 Day Travel Pricing for Two or more people - Selection must be made based on oldest person on this APPLICATION. *Under 64 | Family | $820.0065 to 69 | Family | $1105.0070 to 74 | Family | $1430.0075 to 80 | Family | $1835.00

120 Day Travel Pricing for Two or more people - Selection must be made based on oldest person on this APPLICATION. *Under 64 | Family | $1100.0065 to 69 | Family | $1470.0070 to 74 | Family | $2000.0075 to 80 | Family | $3300.00

180 Day Travel Pricing for Two or more people - Selection must be made based on oldest person on this APPLICATION. *Under 64 | Family | $1905.0065 to 69 | Family | $2345.0070 to 74 | Family | $3170.0075 to 80 | Family | $5325.00

30 Day Travel Pricing *60 to 64 | $202.0065 to 69 | $240.0070 to 74 | $295.0075 to 80 | $685.00

60 Day Travel Pricing *60 to 64 | $285.0065 to 69 | $410.0070 to 74 | $505.0075 to 80 | $875.00

90 Day Travel Pricing *Under 64 | $430.0065 to 69 | $585.0070 to 74 | $755.0075 to 80 | $1270.00

120 Day Travel Pricing *Under 64 | $580.0065 to 69 | $775.0070 to 74 | $1050.0075 to 80 | $1740.00

180 Day Travel Pricing *Under 64 | $1005.0065 to 69 | $1235.0070 to 74 | $1670.0075 to 80 | $2805.00

Are you sending the payment using e-Transfer / e-mail Transfer? *YesNoInstruction for e-Transfer will be on next page after you submit the application.

Save as Draft

travel application

Please allow application time to load or refresh the page.

Please follow the instructions carefully in each section

BEGIN APPLICATION HERE

DATES OF TRAVEL

APPLICANTS INFORMATION

PRIMARY RESIDENCE

SPOUSE INFORMATION

CHILDREN & DEPENDENTS

Second Dependent Medical Questions

ADDITIONAL INFORMATION

*The following 3 questions are subject to additional charges outside of this Travel Application.

If you answered 'Yes' to any of the question we will contact you with product information and pricing.

TRAVEL INSURANCE PRICING

SELECT LENGTH OF TRIP

Allow us the opportunity to provide you a second opinion on your Travel Insurance!

for information and ideas

travel application

Please allow application time to load or refresh the page.

Please follow the instructions carefully in each section

BEGIN APPLICATION HERE

DATES OF TRAVEL

APPLICANTS INFORMATION

PRIMARY RESIDENCE

SPOUSE INFORMATION

CHILDREN & DEPENDENTS

Second Dependent Medical Questions

ADDITIONAL INFORMATION

*The following 3 questions are subject to additional charges outside of this Travel Application.

*If you answered 'Yes' to any of the question we will contact you with product information and pricing.*

TRAVEL INSURANCE PRICING

SELECT LENGTH OF TRIP

Allow us the opportunity to provide you a second opinion on your Travel Insurance!

for information and ideas

If you answered 'Yes' to any of the question we will contact you with product information and pricing.