GMS Application – Visitors 2 Canada Insurance – Medical Emergency Insurance for Tourists and Immigrants to Canada Online

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Personal Data

Single Couple Family

Family members:

1st Applicant

Birthday:

Gender

Male Female

2nd Applicant

Birthday:

Gender

Male Female

3rd Applicant

Birthday:

Gender

Male Female

4th Applicant

Birthday:

Gender

Male Female

5th Applicant

Birthday:

Gender

Male Female

6th Applicant

Birthday:

Gender

Male Female

7th Applicant

Birthday:

Gender

Male Female

8th Applicant

Birthday:

Gender

Male Female

9th Applicant

Birthday:

Gender

Male Female

10th Applicant

Birthday:

Gender

Male Female

How can we contact you?

Canadian Phone

E-mail

What type of visitor are you?

What is your country of origin?

City (In Canada)

Canadian Street Address

Province or Territory

Name of Beneficiary (optional)

Postal Code

Phone

Travel information

You are outside of Canada - No waiting period

When do you arrive in Canada?

You are in Canada and purchasing this plan to replace an existing Canadian health insurance plan. - No waiting period

You have been in Canada for less than 30 days without a Canadian health insurance plan. 2 day (48 hour) waiting period
You have been in Canada for more than 30 days without a Canadian health insurance plan. 7 day (168 hour) waiting period and minimum $1,000 deductible

Deductible

Coverage

Insurance Start Date

Insurance End Date

Do you have a pre-existing medical condition?

Yes No

Total Premium

Payment Details

Credit card number

[?]

CVC( CVV ) Code

[?]

Valid to:

[?]

I acknowledge that I have read and understand the eligibility criteria before purchasing