	May-11-2008 Canada immigration simplified
	We love visitors from the UNITED STATES

New Immigrants: FREE Travel Insurance Quote

Brought to You by Prof-Med

A Division of Professional Planning Solutions Inc.

Please tell us a little more about your planned trip

Persons to be Insured

First Name	Last Name	Date of Birth yy/mm/dd

Please complete the form below - All fields marked with * are required for correct processing of your order.

Destination in Canada:	*
Telephone No.:
Country of Origin:	*
Application Date (Y/M/D):	*
Effective Departure Date: (Y/M/D)	*
Date of Entry (Y/M/D):	*
Number of Days Coverage Required:	*
Any other information we should be aware of:

Please Complete The Awareness Checklist

I understand that this coverage excludes treatment relating to pre-existing medical conditions
I and all the persons coverered under this policy are in good health and have no reason to seek medical attention
I hereby consent, personally and on behalf of all persons covered, to the release of all medical records in the event that there are any claims under this policy
I understand that no person covered under this policy, who is pregnant, will be covered for any treatments related to or arrising from the pregnancy. (Pregnancy is not covered under emergency medical cover) For more info contact us.

YES - I will be taking the optional Doctors on Call package for a nominal extra fee of $1.50 per day.

YES - I will also be taking the optional Death & Disablement coverage with this policy.

By checking this box, I acknowledge that all information provided by me in this form is correct and true. I also hereby accept the ProfMed Conditions of Coverage as stated in the downloadable PDF Travel Insurance Policy.

First Name:	*
Last Name:	*
Email Address:	*

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Canada immigration simplified

New Immigrants: FREE Travel Insurance Quote