DP

DAN PUCHER

TRAVEL MEDICAL INSURANCE BROKER

NORTH AMERICA 877 877 9458 INTERNATIONAL 705 495 3497
UK CONTACT 01333352118

Highlights & Benefits | Deductible Options | Eligibility | Waiting Period | Pre-Existing Conditions | Rates | Policy | Application

TRAVEL UNDERWRITERS
VISITORS TO CANADA - PLATINUM

TRAVEL UNDERWRITERS
VISITORS TO CANADA - PLATINUM

APPLICATION FORM

Client Information:

Sex M/F	First Name	Last Name	Birth Date (DD/MM/YYYY)

Mailing Address in Canada

Street:
City:
Postal Code:
Telephone Number:
Email Address:
Beneficiary Name:
Relationship:

Plan Information:

Application Date (DD/MM/YYYY):
Arrival Date in Canada (DD/MM/YYYY):
Expiry Date (DD/MM/YYYY)

Sum Insured:
Family Plan: (based on rate of oldest person)	Y/N
Deductible Option:
Optional Pre-existing Conditions Coverage Rider for persons 70-79 yrs:		Y/N

Payment Method:

VISA	MasterCard	AMEX	Cheque/Cash
Card No.:
Expiry Date:
Cardholder Name:

Cardholder Signature

Date: (MM/DD/YYY)