International Students

International Student Insurance Application


Fill out this form and email it to [email protected] or
Mail it to:
880 Regina Street, Unit #102
North Bay, Ontario P1B 2K6
Effective Date:
Expiry Date:
Family Plan: Yes No
Beneficiary:
First Name:
Last Name:
Birth Date:
Address:
Phone Number:
Email Address:
Credit Card Information:
Card Type:
Card Number:
Card Expiry Date:
Cardholder's Name: