VISITORS TO CANADA
SUPER VISA
INTERNATIONAL STUDENTS
(Family)

This product only applies to Ontario residents. If you reside outside of Ontario, this product WILL NOT apply to you

You will not be eligible for coverage if you have any of the following conditions

Have been advised by a physician to avoid travel at this time
Have a terminal illness or metastatic cancer
Require kidney dialysis
Have been prescribed or used home oxygen in the last twelve (12) months
never have had bone marrow, stem cell or organ transplant (except corneal transplant)

Adult 1

First Name

Last Name

Date of Birth

MM

DD

YYYY

Adult 2

First Name

Last Name

Date of Birth

MM

DD

YYYY

Child 1

First Name

Last Name

Date of Birth

MM

DD

YYYY

Child 2

First Name

Last Name

Date of Birth

MM

DD

YYYY

Child 3

First Name

Last Name

Date of Birth

MM

DD

YYYY

Child 4

First Name

Last Name

Date of Birth

MM

DD

YYYY

Phone

(###)

###

####

Email

Destination

List all countries you will be visiting

Coverage Start Date

MM

DD

YYYY

Coverage End Date

This the the date you will be back to Ontario, Canada

MM

DD

YYYY

Coverages

Choose the coverage you would like to purchase

COVID-19

Trip Cancellation and Interruption

Single Trip Emergency Medical

Single Trip all Inclusive

Please list all current medical condition that you are taking drugs for

Please include for both adult and child applicant

Coverage will not pay any expenses relating to: a pre-existing medical condition that is not stable in the three (3) months before your effective date; and/or, your heart condition if, in the three (3) months before your effective date, any heart condition has not been stable or you have taken any form of nitroglycerine for the relief of angina pain; and/or, your lung condition if, in the three (3) months before your effective date, any lung condition has not been stable or you required treatment with oxygen or Prednisone for your lung condition. See the policy for a detailed list of limitations and exclusions.

VISITORS TO CANADASUPER VISA INTERNATIONAL STUDENTS(Family)

VISITORS TO CANADA
SUPER VISA
INTERNATIONAL STUDENTS
(Family)