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? 

STEP 1: 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.
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:

STEP 2 : ELIGIBILITY:

You must meet the Eligibility Requirements set out below to be eligible for coverage under this policy. You are eligible for coverage if:
  1. You are at least 15 days old and You are age 89 or under and not insured or eligible for benefits under a Canadian Government Health Insurance Plan; and
  2. You know of no reason why you would require medical attention during your trip; and
  3. In the 12 months prior to the effective date you have not:
    1. been prescribed home oxygen or prednisone for a lung condition or a heart condition or had Pulmonary Fibrosis or Cystic Fibrosis;
    2. used nitroglycerine in any form (spray, patch or pill) for a heart condition for the relief of angina or chest pain, or have a heart condition with an ejection fraction of LESS THAN 40%;
    3. had any aneurysm that is not surgically repaired;
  4. You have not had a Bone Marrow transplant, stem cell transplant or an organ transplant except a cornea transplant.
I have read the Eligibility Requirements above. I understand them, and declare that I am eligible. I acknowledge that any policy and coverage provided to me on the basis of the answers given will be deemed null and void if any answer is not correct.

I confirm I am eligible.

Notes
Please enter any additional, pertinent information and any other information relating to your health here: (500 characters)

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