Visitors to Canada Insurance



Application for Visitors to Canada Insurance


 First Name

Last  Name

Date of birth (dd/mmm/yyyy)


Applicant 1



Male     Female

Applicant 2

Male     Female

Applicant 3

Male     Female

Applicant 4

Male     Female

Applicant 5

Male     Female

Applicant 6

Male     Female

Applicant 7

Male     Female



Visitors Type                        Country of Origin 

Coverage Type:     Individual       Family       Couple (Travel Companions)

Amount of Coverage (per insured)

  (For Super Visa application, minimum coverage is $100,000)

      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.
** Coverage for Pre-existing Medical Conditions is not available for applicants 86+ years of age.

Date of arrival in Canada


 Effective date


 Expiry date

For Super Visa application, minimum number of coverage days is 365 days.


Address in Canada:

Street         Apt.

City        Province        Postal Code     


           Best time to Call    




      Additional Information

Please confirm your E-mail   





Close Window

Revised: March 10, 2019