Debangshu Chakroborty

1 (647) 860-1022

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Health insurance covers up to $200,000. Please read the policy before filling out the application.

This product is underwritten by Industrial Alliance Insurance and Financial Services Inc.
What is your birth date? 

TRAVEL AND TRIP INFORMATION

Effective Date of this policy
Termination Date of this policy
OR Duration of coverage days
Coverage Details:    
Application Type?
Super Visa must be purchased for 365 days; a monthly billing option is available.
For shorter trips, select Visitor, Immigrant, Returning Canadian.



Note: Super Visa requires a single application for each party.

Note: This applies only if you are a student registered at a Canadian School.
Family, Couple or Single Coverage?
Note: Family denotes two adults plus dependants, Couple denotes two adults only.
The Birth Date of the eldest member must be used above.
Coverage: (Choose the desired limit)  
Country of origin or last residence:  
Allowances:    
Have you purchased a policy from us last year?
 
Is your travelling companion insured by us? (Receive a 5% allowance.)
Companion's name:
Name of your Beneficiary: Relationship:
Notes
Please enter any additional, pertinent information and any other information relating to your health here: (500 characters)

PRE-EXISTING CONDITIONS ARE NOT COVERED WITH THIS APPLICATION.


Available Actions: