TRAVEL MEDICAL INSURANCE

INTERNATIONAL STUDENTS

International Students FAX/Mail Quote-Application Form

Please fill in the required information then print it out, SIGN IT IN BOTH PLACES, and send it by mail or FAX to the address or FAX number below.

FAX:

Toll Free FAX:

Address:

604-331-1042

1-888-298-6526

Suite 1406-1030 West Georgia StreetVancouver, BC, Canada V6E 2Y3

International Student Medical and Hospital Insurance Plan

* This form is for new applicants only. If you are renewing or extending your insurance coverage, please contact us.

International Student Medical Insurance Plan Eligibility Requirements

  1. You must be a student of foreign nationality.
  2. You must be enrolled full-time in a recognized institution of learning.
  3. You must not be a Canadian citizen or landed immigrant.
  4. You must be a new applicant for this insurance.
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MEDICAL AND HOSPITAL RATES
Days 30 - 365 Days Optional Coverage
69 years and under $ 1.50 /daily $ 20.00/policy
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
Optional Coverage: Yes    

Effective Date: Y/M/D

year is 4 digits, ie: 2008

Expiry Date: Y/M/D

year is 4 digits, ie: 2008 		No. of Days Coverage
/ / / / Days
* Please make sure you enter the correct day, as the drop down menu has 31 days available regardless of the month (eg. please do not enter Feb. 30 or 31 or April 31)

Estimated Premium in Canadian Dollars:

 $
Name: Surname
 First Names
Address While in Canada:
City: Province:
Postal Code: Sex:Male Female
Day Phone: ( ) - Fax:( ) -
Email: Date of Birth: YYYY MM D
Next of Kin (beneficiary):
Name of School:
Address:
Phone:( ) - Postal Code:
Country of permanent residence:
Treating or family physician in country of permanent residence:
I hereby apply for coverage and understand that coverage will become effective on my arrival date in Canada provided I apply on or before that date, otherwise coverage will be effective on the date my application is accepted by the insurer, or their authorized agent.

Today's Date: Y M D / /

Applicant's Signature:_______________________________________________________________
Arrival Date in Canada: Y M D / /
Agent's Signature: _______________________________________________________________

I, , have not seen a doctor nor been to hospital since my arrival in Canada. I am in good health at the present time and have no intention of claiming as of today's date and time. I hereby certify all the above information is true and accurate.

Date: Y M D
/ / 		Time: H : M
: AM PM

Signature:_______________________________________________________________
PLEASE NOTE: There is a 48-hour waiting period on Sickness.

Estimated Premium in Canadian Dollars:

 $
Paid By: Cheque Mailed Number:
Exp: M / Y
Cash
Charge Mastercard
Charge Visa

Signature of card holder :_______________________________________________________________

Please fill in the required information then print it out, SIGN IT IN BOTH PLACES,
and send it by mail or FAX to the address or FAX number.