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Coverage Details
Company Name
(Required)
Plan Name
(Required)
Arrival/Start Date
MM slash DD slash YYYY
Departure/End Date
MM slash DD slash YYYY
Coverage Amount (Each)
Deductible
Total Premium
About Applicant/Sponsor
Your/Sponsor Name
(Required)
First
Last
Your Email Address
(Required)
Email Address
Confirm Email Address
Your Phone
(Required)
Your Address
Street Address
Address Line 2
City
ZIP Code
Insured 1
Details of The Insured/Traveler 1
Name
(Required)
First
Last
Date of Birth
(Required)
MM slash DD slash YYYY
Pre-existing medical condition Coverage ?
No
Yes
Pre-Existing Condition/Medication Details
Provide details about prescribed medications, Surgeries, Hospitalizations or health issues
Insured 2
Details of The Insured/Traveler
Name
First
Last
Date of Birth
(Required)
MM slash DD slash YYYY
Pre-existing medical condition Coverage ?
No
Yes
Pre-Existing Condition/Medication Details
Provide details about prescribed medications, Surgeries, Hospitalizations and present/past health issues
Additional Details
Best Time to Call You to Explain Exclusions & process Payment
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8:00 am - 12:00 pm
12:00 pm - 3:00 pm
3:00 pm - 6:00 pm
6:00 pm - 9:00 pm
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I agree to the privacy policy.
This does not constitute an offer to enter into an insurance contract, nor does it bind the company to offer insurance at any specific rate or to any particular group or individual. The details presented here are a summary and do not alter or override the terms outlined in the official policy documents, including the policy, certificate of insurance, and related governing documents, collectively referred to as the ‘Insurance Contract.’
Rates and benefits outlined are governed solely by the terms of the Insurance Contract and may be subject to exclusions and limitations.
We will call you to confirm this and process the transaction.
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2967 Dundas St. W. #897 Toronto, ON M6P 1Z2
416-606-5040
contact@travelpolicy.ca
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