Application for Visitors to Canada Insurance
Reference Number:
Agent Information:
Agent Name: ________________________________________ Agent Code (WFG):__________________
Agent Contact Number: _____________________ Agent Email Address:________________________
Information Relating to Visitor #1
Last Name: _______________________________ First Name: __________________________________
Date of Birth: ________________ Age at Effective Date: __________ Salutation:
Mr.
Mrs.
Ms.
(MM/DD/YYYY)
Information Relating to Visitor #2
Last Name: _______________________________ First Name: __________________________________
Date of Birth: ________________ Age at Effective Date: __________ Salutation:
Mr.
Mrs.
Ms.
(MM/DD/YYYY)
Information Relating to Visitor #3
Last Name: _______________________________ First Name: __________________________________
Date of Birth: ________________ Age at Effective Date: __________ Salutation:
Mr.
Mrs.
Ms.
(MM/DD/YYYY)
Information Relating to Visitor #4
Last Name: _______________________________ First Name: __________________________________
Date of Birth: ________________ Age at Effective Date: __________ Salutation:
Mr.
Mrs.
Ms.
(MM/DD/YYYY)
Information Relating to Visitor #5
Last Name: _______________________________ First Name: __________________________________
Date of Birth: ________________ Age at Effective Date: __________ Salutation:
Mr.
Mrs.
Ms.
(MM/DD/YYYY)
Visitors Type:
Super Visa
Visitor
Work or Student
Country of Origin: ___________________________________
New Immigrant
Family
Single
Family coverage is available at two times the rate for the eldest adult under 70 years of age and includes dependent
children under 21 years of age provided the effective and expiry dates are the same and all family members reside
at the same address in Canada
To be eligible for coverage, on the effective date, you must:
• be a visitor to Canada or a person in Canada under a valid work or student visa, a Canadian or an immigrant
not eligible for benefits under a government health insurance plan; and
• be at least 15 days of age and less than 90 years of age (70 years of age for Premium Plan); and
• apply for coverage prior to your arrival in Canada or within 30 days or your arrival in Canada, unless it is the continuation
of an existing Visitors to Canada policy issued by the insur5er with no lapse in coverage; and
• not be travelling against the advice of a physician and/or not have been diagnosed with a terminal illness; and
• not be experiencing new or undiagnosed signs or symptoms and/or know of any reason to seek medical attention; and
• not require assistance with the activities of daily living (dressing, bathing, eating, using the toilet or getting in or out of a
bed or chair).
Information Relating to Sponsor
Sponsor’s Last Name: __________________________ First Name: ______________________________
Sponsor’s Address: _____________________________________________________________________
City: _____________________________ Province: _________________ Postal Code: ________________
Contact Number in Canada: Home: _________________________ Cell ____________________________
Email Address: __________________________________ Language ______________________________
Coverage Information
Effective Date (From): ________________________Expiry Date (To): _______________________________
(MM/DD/YYYY)
(MM/DD/YYYY)
Application Date: _________________#of Days Covered: ___________ Arrival Date ___________________
(MM/DD/YYYY)
Policy Limit:
Policy Type:
X
(MM/DD/YYYY)
$25,000
$50,000
$100,000
Standard
Enhanced
Premium
Deductible Amount: ______________ Premium /Day: _______ Premium Amount: _____________________
Declaration and Authorization (You must read, sign, and date the following.)
I declare that I/The Insureds meet the eligibility requirements for the coverage chosen. The answers I have
provided are truthful, complete and accurate. Misrepresentation or failure to disclose any material fact may void
the policy at the option of the insurer. No coverage will be in effect until the application has been approved by
Berkley Canada.
I am aware that it is my responsibility to review my policy upon receipt in order to understand the coverage and
exclusions, including the pre-existing conditions exclusion, and how they relate to me and my effective date.
I understand Berkley Canada, its agents, and administrators are obliged to collect and retain certain personal
and/or health information about me in connection with my insurance coverage. They will use, retain, and
disclose this information only for the purposes of administering my policy/policies of insurance, providing
customer service, and assessing and paying claims.
_________________________________________
Signature of the Sponsor / Insured
___________________________
Date (MM/DD/YYYY)
Credit Card Authorization
Name of the Cardholder: ________________________________________________________________
Address of the Cardholder:______________________________________________________________
City:__________________________________ State: ________________ Postal Code: ______________
Credit Card Type:
VISA
MasterCard Expiry Date: ____________________________________
Credit Card Number: _____________________________________________ CCV: __________________
I hereby authorize Reliance Innovative Marketing Inc. to deduct my credit card with the premium
amount $ ___________________as mentioned above, on behalf of Berkley Insurance Canada.
_________________________________________
Signature of the Cardholder
___________________________
Date (MM/DD/YYYY)