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International Student Medical Insurance

 

Allianz Global Assistance


Application

INTERNATIONAL STUDENT EMERGENCY HOSPITAL MEDICAL INSURANCE

  Standard Plan (no coverage for pre-existing medical conditions, no Maternity benefit)

  Enhanced Plan (90-day stability period for pre-existing medical conditions)


 First Name

Last  Name

Date of birth (dd/mmm/yyyy)

Gender

Student

 

 

Male     Female

Spouse

Male     Female

Child

Male     Female

Child

Male     Female

Child

Male     Female

Child

Male     Female


Country of Origin

 

 

Name of School

 

Date of arrival in Canada

(dd/mmm/yyyy)  

Effective date

(dd/mmm/yyyy)

Expiry date

(dd/mmm/yyyy)  

Beneficiary in case of death 

 

Coverage for  Pre-existing Medical Conditions is required *

 

* Pre-existing  Medical Condition means injury, illness or disease; symptom(s) that exists before the effective date of insurance.

 

Address in Canada:

Street         Apt.

City        Province        Postal Code     

   

 Telephone

           Best time to Call    

E-mail

 

 

      Additional Information

Please confirm your E-mail   

 

 

 

 

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Revised: December 25, 2017