Student Travel Insurance Request
Step 1 of 10
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1. First, please tell us a bit about yourself.
First Name:
*
Last Name:
*
Gender:
*
Male
Female
Other
Date of Birth (MM/DD/YYYY):
*
Date Format: MM slash DD slash YYYY
2. What is your city and country of residence?
City:
*
Country:
*
3. Do you smoke?
Do you smoke?
*
Yes
No
4. What kind of student travels are you doing?
What type of travelling student are you?
I am a Canadian studying outside of Canada
I am a Canadian studying in Canada out of province
I am an International Student studying in Canada
If you are an international student coming to Quebec or Ontario, please go to our website and complete the form here:
Click Here
4. When do you start school?
I want my coverage to begin on:
*
Date Format: MM slash DD slash YYYY
6. When do you finish school?
I want my coverage to end on:
*
Date Format: MM slash DD slash YYYY
6. Do you have any pre-existing medical conditions?
Any pre-existing medical conditions?
*
Yes
No
6a. Please describe your medical conditions:
Please describe pre-existing medical condition:
*
7. Please add any additional information here:
Any additional information?
8. How can we reach you?
Email:
*
Phone Number:
*
Preference:
*
Email
Phone
