Testing Page for Applications

Reason for Travel *Personal / BusinessOther

This policy does not cover:

participation in any professional athletics
participation in acrobatics or stunt flying, mountaineering, hand gliding, scuba diving, any racing or speed contests

View Travel Booklet (English) or Travel Booklet (French)

You are seeing this message because you chose "Other" for Reason for Travel and / or this policy has certain coverage limitations as outlined in the policy booklet, Travel Booklet (English) or Travel Booklet (French). Therefore, you cannot submit this application. Contact us for further assistance.

Please do not proceed

DATES OF TRAVEL

From What Date:

To What Date:

Destination Country:

Will you Travel to additional Countries on your Trip?YesNo

Please Select Additional Countries

Select All That ApplyCanadaUnited StatesAfghanistanÅland IslandsAlbaniaAlgeriaAmerican SamoaAndorraAngolaAnguillaAntarcticaAntigua and BarbudaArgentinaArmeniaArubaAustraliaAustriaAzerbaijanBahamasBahrainBangladeshBarbadosBelarusBelgiumBelizeBeninBermudaBhutanBoliviaBonaire, Sint Eustatius and SabaBosnia and HerzegovinaBotswanaBouvet IslandBrazilBritish Indian Ocean TerritoryBrunei DarussalamBulgariaBurkina FasoBurundiCabo VerdeCambodiaCameroonCayman IslandsCentral African RepublicChadChileChinaChristmas IslandCocos IslandsColombiaComorosCongo, Democratic Republic of theCongo, Republic of theCook IslandsCosta RicaCôte d'IvoireCroatiaCubaCuraçaoCyprusCzech RepublicDenmarkDjiboutiDominicaDominican RepublicEcuadorEgyptEl SalvadorEquatorial GuineaEritreaEstoniaEswatiniEthiopiaFalkland IslandsFaroe IslandsFijiFinlandFranceFrench GuianaFrench PolynesiaFrench Southern TerritoriesGabonGambiaGeorgiaGermanyGhanaGibraltarGreeceGreenlandGrenadaGuadeloupeGuamGuatemalaGuernseyGuineaGuinea-BissauGuyanaHaitiHeard and McDonald IslandsHoly SeeHondurasHong KongHungaryIcelandIndiaIndonesiaIranIraqIrelandIsle of ManIsraelItalyJamaicaJapanJerseyJordanKazakhstanKenyaKiribatiKuwaitKyrgyzstanLao People's Democratic RepublicLatviaLebanonLesothoLiberiaLibyaLiechtensteinLithuaniaLuxembourgMacauMadagascarMalawiMalaysiaMaldivesMaliMaltaMarshall IslandsMartiniqueMauritaniaMauritiusMayotteMexicoMicronesiaMoldovaMonacoMongoliaMontenegroMontserratMoroccoMozambiqueMyanmarNamibiaNauruNepalNetherlandsNew CaledoniaNew ZealandNicaraguaNigerNigeriaNiueNorfolk IslandNorth KoreaNorth MacedoniaNorthern Mariana IslandsNorwayOmanPakistanPalauPalestine, State ofPanamaPapua New GuineaParaguayPeruPhilippinesPitcairnPolandPortugalPuerto RicoQatarRéunionRomaniaRussiaRwandaSaint BarthélemySaint Helena, Ascension and Tristan da CunhaSaint Kitts and NevisSaint LuciaSaint MartinSaint Pierre and MiquelonSaint Vincent and the GrenadinesSamoaSan MarinoSao Tome and PrincipeSaudi ArabiaSenegalSerbiaSeychellesSierra LeoneSingaporeSint MaartenSlovakiaSloveniaSolomon IslandsSomaliaSouth AfricaSouth Georgia and the South Sandwich IslandsSouth KoreaSouth SudanSpainSri LankaSudanSurinameSvalbard and Jan Mayen IslandsSwedenSwitzerlandSyriaTaiwanTajikistanTanzaniaThailandTimor-LesteTogoTokelauTongaTrinidad and TobagoTunisiaTurkeyTurkmenistanTurks and Caicos IslandsTuvaluUgandaUkraineUnited Arab EmiratesUnited KingdomUruguayUS Minor Outlying IslandsUzbekistanVanuatuVenezuelaVietnamVirgin Islands, BritishVirgin Islands, U.S.Wallis and FutunaWestern SaharaYemenZambiaZimbabwe

Countries that you will land in or visit during your trip

APPLICANTS INFORMATION

COPA Active Member Number

COPA Member Since

First Name

Last Name

Date of Birth:

Birthdate *

Age

GenderMaleFemale

PRIMARY RESIDENCE

Street Address

City

Province

Postal Code

Phone

Email Address

Travel - Medical Questions Required for Travel Coverage (Applicant)

The following medical questions are required for all travelers covered on this travel policy aged 65+. Medical questions help us to determine your eligibility and premium rate.

Pre-existing conditions are based on Age of the Traveler(s)

Pre-existing conditions could affect your coverage if the answer to any of the medical questions is 'YES', up to the date of departure for your trip(s). Medical questions help us to determine your eligibility and premium rate.

If the answer to any of the medical questions is 'YES' than a conversation with Arlene Marko, of our Travel Team is required.

1) Have you received medical advice, consultations, or treatment within 3 months (age 65-69), 6 months (age 70-74), or 12 months (age 75-79) prior to the date of departure of a trip out of your home province? *YesNo

Details:

2) Have you received a prescription or a change (up or down) to an existing prescription within 3 months (age 65-69), 6 months (age 70-74), or 12 months (age 75-79) of the date of departure of a trip out of your home province? *YesNo

Details:

3) Do you have a diagnosis for a chronic condition for a disease or disorder which has existed for a minimum of 3 months (age 65-69), 6 months (age 70-74), or 12 months (age 75-79) prior to the date of departure of a trip out of your home province? *YesNo

Details:

4) Have you ever been treated for any form of heart condition or stroke for a minimum of 3 months (age 65-69), 6 months (age 70-74), or 12 months (age 75-79) prior to the date of departure of a trip out of your home province? *YesNo

5) Has your doctor given any indication of any risk because of your health not to travel 3 months (age 65-69), 6 months (age 70-74), or 12 months (age 75-79) prior to date of departure of a trip? *YesNo

Details:

Date of last visit to doctor? *

Exclusions and Limitations

** any condition for which the Insured Person received medical advice, consultation or treatment within six (6) months prior to the commencement of a Trip, with the exception of a Chronic Condition which is under treatment and Stabilized by the regular use of prescribed medication.

"Chronic Condition" means a disease or disorder which has existed for a minimum of six (6) months.

"Stabilized" means there has not been a change in the medical condition requiring medical or psychiatric intervention for a minimum of six (6) months, adjustments in doses of Warfarin or Coumadin are not considered to be medical intervention for the purpose of this definition.

SPOUSE INFORMATION

Do You Have A Spouse? *YesNo

First Name

Last Name

Date of Birth:

Birthdate *

Age

GenderMaleFemale

Travel - Medical Questions Required for Travel Coverage (Spouse)

The following medical questions are required for all travelers covered on this travel policy aged 65+. Medical questions help us to determine your eligibility and premium rate.

Pre-existing conditions are based on Age of the Traveler(s)

If the answer to any of the medical questions is 'YES' than a conversation with Arlene Marko, of our Travel Team is required.

Details:

Date of last visit to doctor? *

Exclusions and Limitations

**any pre-existing medical condition that is not stable in the three (3) months before your trip, and/or, any heart condition that has not been stable or you have taken any form of nitroglycerine for the relief of angina pain in the three (3) months before your trip.

"Chronic Condition" means a disease or disorder which has existed for a minimum of six (6) months.

CHILDREN & DEPENDENTS

Do You Have Dependents Traveling on this Trip? *YesNo

Select DependentsChildrenElderly Parent(s)

How many Children will be Traveling?1-21-31-41-51-61-10

First & Last NameChild 1

Date of Birth:Child 1

First & Last NameChild 2

Date of Birth:Child 2

First & Last NameChild 3

Date of Birth:Child 3

First & Last NameChild 4

Date of Birth:Child 4

First & Last NameChild 5

Date of Birth:Child 5

First & Last NameChild 6

Date of Birth:Child 6

First & Last NameChild 7

Date of Birth:Child 7

First & Last NameChild 8

Date of Birth:Child 8

First & Last NameChild 9

Date of Birth:Child 9

First & Last NameChild 10

Date of Birth:Child 10

How many Elderly Parent(s) will be Traveling?11-2

First & Last Name *Please list oldest dependent first.

Date of Birth:

Month

Day *

Year *

Age:

Travel - Medical Questions Required for Travel Coverage (Dependent)

The following medical questions are required for all travelers covered on this travel policy aged 65+.

Pre-existing conditions are based on Age of the Traveler(s)

Pre-existing conditions could affect your coverage if the answer to any of the medical questions are 'YES', up to the date of departure for your trip(s).

If the answer to any of the medical questions are 'YES' than a conversation with Arlene Marko, of our Travel Team is required.

Details:

Date of last visit to doctor? *

Second Dependent

First & Last NameDependent 2

Date of Birth:

Month

Day *

Year *

Age:

Details:

Date of last visit to doctor? *

Exclusions and Limitations

"Chronic Condition" means a disease or disorder which has existed for a minimum of six (6) months.

ADDITIONAL INFORMATION

Are you a Business Owner? *YesNo

Company Name:

Are you Retired? *YesNo

Were you referred to us? *YesNo

Name of Referrer

*The following 3 questions are subject to additional charges outside of this Travel Application.

*Do you require Travel Interruption Protection? *YesNo

*Do you require Trip Cancelation Protection? *YesNo

*Do you require Kidnap & Ransom Insurance? *YesNo

If you answered 'Yes' to any of the above questions a member of our Travel Team will contact you with product information and pricing.

TRAVEL INSURANCE PRICING

SELECT LENGTH OF TRIP

Length of Trip45 Days90 Days120 Days180 Days

Length of Trip with Two or more people45 Days90 Days120 Days180 Days

45 Day Travel Pricing for Two or more people - Selection must be made based on oldest person on this APPLICATION. *Under 69 | $222.0070 - 74 | $386.0075 - 79 | $772.00

90 Day Travel Pricing for Two or more people - Selection must be made based on oldest person on this APPLICATION. *Under 64 | Family | $736.0065 to 69 | Family | $1,009.0070 to 74 | Family | $1,580.0075 to 80 | Family | $2,706.00

120 Day Travel Pricing for Two or more people - Selection must be made based on oldest person on this APPLICATION. *Under 64 | Family | $992.0065 to 69 | Family | $1,487.0070 to 74 | Family | $2,281.0075 to 80 | Family | $4,110.00

180 Day Travel Pricing for Two or more people - Selection must be made based on oldest person on this APPLICATION. *Under 64 | Family | $2,266.0065 to 69 | Family | $3,224.0070 to 74 | Family | $4,920.0075 to 80 | Family | $7,104.00

45 Day Travel Pricing *Under 69 | $222.0070 - 74 | $386.0075 - 79 | $772.00

90 Day Travel Pricing *Under 64 | $388.0065 to 69 | $532.0070 to 74 | $832.0075 to 80 | $1,425.00

120 Day Travel Pricing *Under 64 | $522.0065 to 69 | $783.0070 to 74 | $1,200.0075 to 80 | $2,164.00

180 Day Travel Pricing *Under 64 | $1,193.0065 to 69 | $1,697.0070 to 74 | $2,590.0075 to 80 | $3,740.00

SAVE DRAFT

Reason for Travel *Personal / BusinessOther

This policy does not cover:

participation in any professional athletics
participation in acrobatics or stunt flying, mountaineering, hand gliding, scuba diving, any racing or speed contests

View Travel Booklet (English) or Travel Booklet (French)

Please do not proceed

DATES OF TRAVEL

Estimated Date of Departure: *

Estimated Date of Return: *

Destination Country: *

Will you Travel to additional Countries on your Trip? *YesNo

Please Select Additional Countries

Countries that you will land in or visit during your trip

APPLICANTS INFORMATION

COPA Active Member Number *

COPA Member Since *

First Name *

Last Name *

Date of Birth:

Month *

Day *

Year *

Age *

Gender *MaleFemale

Calculated Age

PRIMARY RESIDENCE

Street Address *

City *

Province *

Postal Code *

Phone *

Email Address *

Travel - Medical Questions Required for Travel Coverage (Applicant)

The following medical questions are required for all travelers covered on this travel policy aged 65+. Medical questions help us to determine your eligibility and premium rate.

Pre-existing conditions are based on Age of the Traveler(s)

If the answer to any of the medical questions is 'YES' than a conversation with Arlene Marko, of our Travel Team is required.

Details:

Date of last visit to doctor? *

Exclusions and Limitations

"Chronic Condition" means a disease or disorder which has existed for a minimum of six (6) months.

SPOUSE INFORMATION

Do You Have A Spouse? *YesNo

First Name

Last Name

Date of Birth:

Month *

Day *

Year *

Age *

Gender *MaleFemale

Calculated Age

Travel - Medical Questions Required for Travel Coverage (Spouse)

The following medical questions are required for all travelers covered on this travel policy aged 65+. Medical questions help us to determine your eligibility and premium rate.

Pre-existing conditions are based on Age of the Traveler(s)

If the answer to any of the medical questions is 'YES' than a conversation with Arlene Marko, of our Travel Team is required.

Details:

Date of last visit to doctor? *

Exclusions and Limitations

"Chronic Condition" means a disease or disorder which has existed for a minimum of six (6) months.

CHILDREN & DEPENDENTS

Do You Have Dependents Traveling on this Trip? *YesNo

Select DependentsChildrenElderly Parent(s)

Children

Child's Full Name *

Birthdate *

Elderly Dependents

Full Name *

Birthdate *

Age *

Full Name

Birthdate

Age

Travel - Medical Questions Required for Travel Coverage (Dependent)

The following medical questions are required for all travelers covered on this travel policy aged 65+.

Pre-existing conditions are based on Age of the Traveler(s)

Pre-existing conditions could affect your coverage if the answer to any of the medical questions are 'YES', up to the date of departure for your trip(s).

If the answer to any of the medical questions are 'YES' than a conversation with Arlene Marko, of our Travel Team is required.

Details:

Date of last visit to doctor? *

Second Dependent Medical Questions

Details:

Date of last visit to doctor? *

Exclusions and Limitations

"Chronic Condition" means a disease or disorder which has existed for a minimum of six (6) months.

ADDITIONAL INFORMATION

Are you a Business Owner? *YesNo

Company Name:

Are you Retired? *YesNo

Were you referred to us? *YesNo

Name of Referrer

*The following 3 questions are subject to additional charges outside of this Travel Application.

*Do you require Travel Interruption Protection? *YesNo

*Do you require Trip Cancelation Protection? *YesNo

*Do you require Kidnap & Ransom Insurance? *YesNo

If you answered 'Yes' to any of the above questions a member of our Travel Team will contact you with product information and pricing.

TRAVEL INSURANCE PRICING

SELECT LENGTH OF TRIP

Length of Trip45 Days60 Days90 Days120 Days180 Days

Length of Trip with Two or more people45 Days60 Days90 Days120 Days180 Days

45 Day Travel Pricing for Two or more people - Selection must be made based on oldest person on this APPLICATION. *Under 69 | $222.0070 - 74 | $386.0075 - 79 | $772.00

60 Day Travel Pricing for Two or more people - Selection must be made based on oldest person on this APPLICATION. *Under 64 | $540.0065 to 69 | $780.0070 to 74 | $955.0075 to 80 | $1,665.00

90 Day Travel Pricing for Two or more people - Selection must be made based on oldest person on this APPLICATION. *Under 64 | Family | $820.0065 to 69 | Family | $1,105.0070 to 74 | Family | $1,430.0075 to 80 | Family | $1,480.00

120 Day Travel Pricing for Two or more people - Selection must be made based on oldest person on this APPLICATION. *Under 64 | Family | $1,100.0065 to 69 | Family | $1,470.0070 to 74 | Family | $1,995.0075 to 80 | Family | $3,300.00

180 Day Travel Pricing for Two or more people - Selection must be made based on oldest person on this APPLICATION. *Under 64 | Family | $1,905.0065 to 69 | Family | $2,345.0070 to 74 | Family | $3,170.0075 to 80 | Family | $5,325.00

45 Day Travel Pricing *Under 69 | $222.0070 - 74 | $386.0075 - 79 | $772.00

60 Day Travel Pricing *Under 64 | $285.0065 to 69 | $410.0070 to 74 | $505.0075 to 80 | $875.00

90 Day Travel Pricing *Under 64 | $395.0065 to 69 | $585.0070 to 74 | $755.0075 to 80 | $1,270.00

120 Day Travel Pricing *Under 64 | $580.0065 to 69 | $775.0070 to 74 | $1,050.0075 to 80 | $1,740.00

180 Day Travel Pricing *Under 64 | $1,005.0065 to 69 | $1,235.0070 to 74 | $1,670.0075 to 80 | $2,805.00

SAVE DRAFT

Testing Page for Applications

DATES OF TRAVEL

DATES OF TRAVEL

APPLICANTS INFORMATION

PRIMARY RESIDENCE

Travel - Medical Questions Required for Travel Coverage (Applicant)

SPOUSE INFORMATION

CHILDREN & DEPENDENTS

Second Dependent Medical Questions

ADDITIONAL INFORMATION

*The following 3 questions are subject to additional charges outside of this Travel Application.

*If you answered 'Yes' to any of the above questions a member of our Travel Team will contact you with product information and pricing.*

TRAVEL INSURANCE PRICING

SELECT LENGTH OF TRIP

If you answered 'Yes' to any of the above questions a member of our Travel Team will contact you with product information and pricing.