Fill in the information in the light blue shaded boxes , then click the quotation button below. It will automatically quote the number of days coverage and the total cost of the insurance.
<= Quotation Button
Plan
-------------- USA Plan Non-USA Plan
$0 Deductible (10% up)
Yes No
Destination
Effective Date : Y/M/D
Expiry Date : Y/M/D
Number of Days Coverage
Days
No. 1
First Name :
Last Name :
Date of Birth : Year (4 digits) / January February March April May June July August September October November December / 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31
Gender : M F
Daily Rate / Age at Effective Date :$ /
Premium : $
No. 2
Relationship with 1 -------- Spouse Parent Child Sibling Companion
No. 3
No. 4
Total: $
Please fill in the following.
Mailing Address in Canada:
Suite No.:
City/Province:
Postal Code:
Tel:
Email:
Email (Confirmation):
Pay by: VISA MC AMEX
Card Holder Name:
Card Number:
Expiry Date: M/Y: 1 2 3 4 5 6 7 8 9 10 11 12 / 2024 2025 2026 2027 2028 2029 2030 2031 2032 2033
CVV:
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