Please fill the form in English. We will contact you within 24 hours.

    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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