COVERAGE TYPE *

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Annual multi-trip
Single Trip
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PROVINCE/TERRITORY OF RESIDENCE *

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Alberta
British Columbia
Manitoba
New Brunswick
Newfoundland and Labrador
Northwest Territories
Nova Scotia
Nunavut
Ontario
Prince Edward Island
Quebec
Saskatchewan
Yukon
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Provincial/Federal healthcare coverage

Please check box if all insureds have valid provincial or federal healthcare coverage. Number of travellers

NUMBER OF TRAVELERS *

Date of birth *

TOTAL TRIP COST OF ALL TRAVELLERS (OPTIONAL) *

$

Phone *

Email *

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