Canadian Student Application - Danforth Insurance

Coverage dates: January 7, 1980 to January 7, 1982

Quotes Accepted:

Applicant	Plan	Coverage	Deductable	Premium
1	Enhanced	$200,000	$10,000	$10,000.00
2	Enhanced	$200,000	$10,000	$10,000.00
3	Enhanced	$200,000	$10,000	$10,000.00
4	Enhanced	$200,000	$10,000	$10,000.00
5	Enhanced	$200,000	$10,000	$10,000.00

Minimum Adjustment Charges:

Total Premium:

You are enrolled in monthly payment plan:

Monthly Payment Plan:

Monthly installment: $500

Payment due today: $500 (2 months instalment) + $50 (one time fee) = $1000

Applicants Information

Applicant 1 (Birthdate: January 31, 2020)

Given Name(s) *

Last Name *

Gender *

Age 40 years

Applicant 2 (Birthdate: January 31, 2020)

Given Name(s) *

Last Name *

Gender *

Age 40 years

Applicant 3 (Birthdate: January 31, 2020)

Given Name(s) *

Last Name *

Gender *

Age 40 years

Applicant 4 (Birthdate: January 31, 2020)

Given Name(s) *

Last Name *

Gender *

Age 40 years

Applicant 5 (Birthdate: January 31, 2020)

Given Name(s) *

Last Name *

Gender *

Age 40 years

Address in Canada

Street Adress: *

City: *

Province: *

Postal Code: *

Home Phone: *

Work Phone

Email: *

Confirm Email: *

How would you like to pay? *

Error message

Payment Details

Payment amount $500.00

Card type: * Visa Mastercard

Name on card: *

Card number: *

Card Expiry: *

Security code: *

Error Message:

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