Contact Name (required)

    Contact Email (required)

    Contact phone number (required)

    Number of people to be insured (required)

    Start date YYYY=Year, MM=Month, DD=Date (required)

    End date YYYY=Year, MM=Month, DD=Date (required)

    Arrival date YYYY=Year, MM=Month, DD=Date (required)

    Country of origin (required)

    Beneficiary name (required)

    Sum insured
    Deductible: Insurance benefit:

    Passengers information:
    First name:
    Last name:
    Gender: MF
    Birthday:
    Address in Canada:

    Other passengers:
    First name:
    Last name:
    Gender: MF
    Birthday:
    Address in Canada:

    First name:
    Last name:
    Gender: MF
    Birthday:
    Address in Canada:

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