Visitor to Canada Application - Danforth Insurance

Quotes Accepted:

Coverage dates: January 7, 2929 to January 12, 2909

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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

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 (Birth date: January 10, 2029)

Given Name(s)

Last Name

Gender

Age 40 years

Applicant 1 (Birth date: January 10, 2029)

Given Name(s)

Last Name

Gender

Age 40 years

Applicant 1 (Birth date: January 10, 2029)

Given Name(s)

Last Name

Gender

Age 40 years

Applicant 1 (Birth date: January 10, 2029)

Given Name(s)

Last Name

Gender

Age 40 years

Applicant 1 (Birth date: January 10, 2029)

Given Name(s)

Last Name

Gender

Age 40 years

Travel Information

Country of origin

Destination province

Arrival date Canada arrival date - can be same or before insurance start date

Address in Canada

Address line 1:*

Address line 2:

City:*

Province:*

Postal code:*

Home Phone:*

Work Phone:

Email:*

Confirm Email:*

How would you like to pay?*

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Credit card information

Payment Due: ___

Card type * Visa Mastercard

Name on card: *

Card number: *

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