Visitor to Canada Blue Cross Application

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Trip details

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Your quote

Traveller details

Payment

Confirmation

Coverage dates: January 7, 1980 to January 10, 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:

Applicants Information

Applicant 1 (Birthdate: January 31, 2020)

Given Name(s) *

Last Name *

Gender *

Applicant 2 (Birthdate: January 31, 2020)

Given Name(s) *

Last Name *

Gender *

Relationship to Applicant 1 *

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Applicant 3 (Birthdate: January 31, 2020)

Given Name(s) *

Last Name *

Gender *

Relationship to Applicant 1 *

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Applicant 4 (Birthdate: January 31, 2020)

Given Name(s) *

Last Name *

Gender *

Relationship to Applicant 1 *

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Applicant 5 (Birthdate: January 31, 2020)

Given Name(s) *

Last Name *

Gender *

Relationship to Applicant 1 *

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Relationship between applicants

All applicants must be members of the same family. If any applicant is not a family member then please purchase insurance policy for that applicant separately. Please go back to plans.

Travel Information

Country of origin: *

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Destination province: *

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Arrival date: *

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Address in Canada

Street Address: *

Street Address 2

City: *

Province: *

Postal Code: *

Phone: *

Email: *

Confirm Email: *

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