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First Name *

Family Name *

E-Mail *

Phone number *

Preferred Language to communicate with you * EnglishFrançaisMandarinCantoneseHindiGujrati

Number of travelers including yourself * 123456

Preferred way to reach you PhoneE-Mail

Age of Traveler #1 *

Age of Traveler #2

Age of Traveler #3

Age of Traveler #4

Place of Residence - Province/Country *

Destination * Within CanadaUnited States of AmericaInternational (excluding USA)

Departure Date *

Return Date *

Type of coverage * Single Trip Emergency MedicalMulti-Trip Emergency MedicalAll-Inclusive Single TripAll-Inclusive Multi-TripVisitor to CanadaSuper Visa (1 year)

For Visitor to Canada only - Select desired coverage amount $10 000$15 000$25 000$50 000$100 000

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