Allianz Visitors to Canada

Step 1 of 4

Date of Birth - Primary Applicant*
Month
Day
Year
Age*
Age Bracket
Select Number of Additional Travellers*
Additional Applicants 1 Date de Birth
MM slash DD slash YYYY
Age - Additional Traveller 1
Age Bracket - Additional Traveller 1
Additional Applicants 2 Date of Birth
MM slash DD slash YYYY
Age - Additional Traveller 2
Age Bracket - Additional Traveller 2
Effective Date*

MM slash DD slash YYYY
Expiry Date*

MM slash DD slash YYYY
Days of coverage*
Coverage options*
Daily rate*
Daily rate - Additional Traveller 1
Daily rate - Additional Traveller 2
Deductible*

DECLARATION OF THE PRIMARY INSURED

IMPORTANT - PLEASE READ CAREFULLY

IMPORTANT

Please read the eligibility requirements, pre-existing conditions, and privacy statement carefully, before agreeing to the declaration of the primary insured. If you have any questions or concerns, contact 1-800-607-1920

ELIGIBILITY
1. Coverage is NOT AVAILABLE to any individual who, as of their effective date:
  1. has been diagnosed with a terminal illness; or
  2. has been diagnosed with stage 3 or 4 cancer: or
  3. received treatment for any cancer (other than basal or squamous cell skin cancer or breast cancer treated only with hormone therapy) in the past 3 months; or
  4. requires assistance with activities of daily living as the result of a medical condition or state of health.
2. To be eligible for coverage you must, as of the effective date:
  1. be at least 15 days old and not more than 89 years old; and
  2. not be insured or eligible for benefits under a Canadian Government Health Insurance Plan; and
  3. be in good health at the time you purchase your policy and on the date you exit your country of origin, and know of no reason to seek medical consultation during the period of coverage.
Do you have a pre-existing medical condition?

Individuals with a pre-existing condition may not be able to purchase travel insurance online. To provide you with an accurate quote and purchase travel insurance for you or your travelling companions that have a pre-existing medical condition, please call us at 1-800-607-1920.We will be happy to assist you.

Your insurance contains pre-existing conditions exclusions for travellers of any age. These exclusions apply to medical conditions and/or symptoms that existed on or before your departure date or effective date. Check to see how this applies to your coverage and how it relates to your departure date, purchase date and effective date.

PRIVACY

I understand that GCAG/assurancevisiteurs.ca, AZGA Service Canada Inc. o/a Allianz Global Assistance and CUMIS General Insurance Company will collect, use, retain, and disclose my personal information to provide me with the requested insurance services and for any other use authorized by me, and/or as required by law. For complete information on your privacy rights, please refer to Privacy Statement.

DECLARATION

I confirm that I have read, understand and agree to all the terms, conditions, limitations and exclusions outlined in this declaration and in the policy.

I have been authorized by any other travellers to apply for insurance coverage on their behalf and to confirm their understanding of and agreement to these terms, conditions, limitations and exclusions.
Consent*
- The applicant confirms his/her eligibility to the plan.

Primary Applicant Age
Number of Additional Travellers
Additional Applicant 1 Age
Additional Applicant 2 Age
Coverage
Total Duration b/w Effective and Expiry Date
Premium
Premium - Additional Applicants
Deductible
Total premium

Primary Applicant
Name*
First Name Last Name
Email*
Gender*
Country of origin*
Date of arrival in Canada*
MM slash DD slash YYYY
Dependents
Number of Additional Travellers
Name - Additional Traveller 1
First Name Last Name
Gender*
Name - Additional Traveller 2
First Name Last Name
Gender*
Primary Applicant's Mailing Address
Address*
Address 1 Address 2 City Postal Code
Phone Number*

Allianz Visitors to Canada

Step 1 of 4

Primary Applicant

Dependents

Primary Applicant's Mailing Address

1-800-607-1920

info@assurancevisiteurs.ca

2001 boul. Robert-Boursassa, suite 1700, Montreal, QC, H3A 2A6

1-800-607-1920

info@assurancevisiteurs.ca

2001 boul. Robert-Boursassa, suite 1700, Montreal, QC, H3A 2A6

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Destination Visitors to Canada Option 2

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International - All countries including the United States (Weekly Rate)

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Rate for Super Visa Insurance $ 100,000 of coverage for one year with $ 0 deductible.

Taux pour assurance super visa 100,000 $ de couverture pour une durée d'un an avec 0$ franchise.

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Tarifs mensuels Expatriés INCLUANT Etats-Unis et Mexique (Monde entier)

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