travel & renewal application Important reason to disclose all medical history. Read MoreBooking times for additional Travel Insurance. Learn MorePlease allow application time to load or refresh the page.Please follow the instructions carefully in each section. Please make sure to add all family members that need to be covered under this policy.Reason for Travel *Personal / BusinessRenewalOtherThis policy does not cover:participation in any professional athleticsparticipation in acrobatics or stunt flying, mountaineering, hand gliding, scuba diving, any racing or speed contestsView 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 at (855) 234-3808 ext. 104.Please do not proceedDATES OF TRAVELEstimated Date of Departure: *Estimated Date of Return: *Destination Country: *Please select an optionSelect OneCanadaUnited 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 SaharaYemenZambiaZimbabweWill you Travel to additional Countries on your Trip? *YesNoPlease Select Additional CountriesSelect 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 SaharaYemenZambiaZimbabweCountries that you will land in or visit during your tripAPPLICANTS INFORMATIONCOPA Active Member Number *COPA Member Since *First Name *Last Name *Date of Birth:Month *Day *Year *Age *Gender *MaleFemaleCalculated AgePRIMARY RESIDENCEStreet 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? *YesNoDetails: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? *YesNoDetails: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? *YesNoDetails: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? *YesNo5) 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? *YesNoDetails:Date of last correspondence with doctor? *Phone call, Virtual meeting, In personExclusions 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 INFORMATIONDo You Have A Spouse? *YesNoFirst NameLast NameDate of Birth:Month *Day *Year *Age *Gender *MaleFemaleCalculated AgeTravel - 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)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? *YesNoDetails: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? *YesNoDetails: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? *YesNoDetails: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? *YesNo5) 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? *YesNoDetails:Date of last correspondence with doctor? *Phone call, Virtual meeting, In personExclusions 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.** 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.CHILDREN & DEPENDENTSDo You Have Dependents Traveling on this Trip? *YesNoSelect DependentsChildrenElderly Parent(s)ChildrenChild's Full Name *Birthdate *Elderly DependentsFull Name *Birthdate *Age *Full NameBirthdateAgeTravel - 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.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? *YesNoDetails: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? *YesNoDetails: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? *YesNoDetails: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? *YesNo5) 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? *YesNoDetails:Date of last correspondence with doctor? *Phone call, Virtual meeting, In personSecond Dependent Medical Questions1) 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? *YesNoDetails: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? *YesNoDetails: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? *YesNoDetails: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? *YesNo5) 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? *YesNoDetails:Date of last correspondence with doctor? *Phone call, Virtual meeting, In personExclusions 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.ADDITIONAL INFORMATIONAre you a Business Owner? *YesNoCompany Name:Are you Retired? *YesNoWere you referred to us? *YesNoName 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 PRICINGSELECT LENGTH OF TRIPLength of Trip45 Days60 Days90 Days120 Days180 DaysLength of Trip with Two or more people45 Days60 Days90 Days120 Days180 Days45 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 | $772.0060 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 | $1,662.0090 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 | $2,415.00120 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 | $3,300.00180 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 | $5,325.0045 Day Travel Pricing *Under 69 | $222.0070 - 74 | $386.0075 - 79 | $772.0060 Day Travel Pricing *Under 64 | $285.0065 to 69 | $410.0070 to 74 | $505.0075 to 80 | $875.0090 Day Travel Pricing *Under 64 | $435.0065 to 69 | $585.0070 to 74 | $755.0075 to 80 | $1,270.00120 Day Travel Pricing *Under 64 | $580.0065 to 69 | $775.0070 to 74 | $1,050.0075 to 80 | $1,740.00180 Day Travel Pricing *Under 64 | $1,005.0065 to 69 | $1,235.0070 to 74 | $1,670.0075 to 80 | $2,805.00Are you sending the payment using e-Transfer / e-mail Transfer? *YesNoInstruction for e-Transfer will be on next page after you submit the application.SUBMIT TRAVEL INSURANCE APPLICATION & PROCEED TO PAYMENTSAVE DRAFTAllow us the opportunity to provide you a second opinion on your Travel Insurance! for information and ideas Contact Us
