We carry twelve different policies, as such, we will need to obtain some specific information before we will be able to offer a quote. We will require the following: Leave this field blank First Name (as it appears on your health card) Last Name Date of Birth Phone # Email Address Your list of prescription medications by name (include aspirin if prescribed by a doctor) Period of stability (date of last change in dosage or new or discontinued medication) Diagnosed medical conditions (include date of initial diagnosis) Major surgical procedures Departure Date Return Date Approx. travel dates if exact dates N/A Type of coverage (top-up, Single trip or Multi-trip Annual plan) Single Trip Multi-trip annual plan Multi-trip Annual plan with Top-up Topping up existing coverage enter existing coverage duration below Existing coverage duration (if applicable) Do you smoke (Last 12 months) Yes No Additional Information or Questions Submit Form
