Available to students in Alberta, BC, Ontario, Yukon and Northwest Territories.
We will refer to appropriate agencies for other Provinces.
We will reply to you by e-mail within 1 – 2 business day(s).
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Allianz International Students Insurance – Quote Request Form

To be eligible for coverage, you must:
- a) be a full-time student; or
- b) be a dependent child or the spouse of an eligible student; and
- c) as of the effective date, be less than 60 years of age; and
- d) not be insured or eligible for benefits under a Canadian government health insurance plan; and
- e) be in good health at the time you purchase your policy and on the effective date, and know of no reason to seek treatment or medical consultation during the period of coverage
Do you confirm that you are eligible to apply? *
Eligibility Option
- Yes
- No
If No, you are not eligible to apply for student insurance.
Applicant Information
Applicant 1
Applicant 1: First Name*
Applicant 1: Last Name*
Applicant 1: Date of Birth (mm/dd/yyyy)*
MM slash DD slash YYYY
Applicant 1: Gender*
- Male
- Female
Applicant 2
Applicant 2: First Name
Applicant 2: Last Name
Applicant 2: Date of Birth (mm/dd/yyyy)
MM slash DD slash YYYY
Applicant 2: Gender
- Male
- Female
Relationship to Applicant 1*
Relationship (Other)*
Please specify the relationship between you and the beneficiary.
Applicant 3
Applicant 3: First Name
Applicant 3: Last Name
Applicant 3: Date of Birth (mm/dd/yyyy)
MM slash DD slash YYYY
Applicant 3: Gender
- Male
- Female
Relationship to Applicant 1*
Relationship (Other)*
Please specify the relationship between you and the beneficiary.
Address in Canada
Address*
Address Line 1 * Address Line 2 City * Province * Postal Code *
Telephone Number*
E-mail Address*
Enter Email Confirm Email
Country of Origin*
Please check the wording about the definition of "Country of origin".
Coverage Dates
Effective Date (mm/dd/yyyy)*
MM slash DD slash YYYY
Please enter the effective date at least 5 days after today.
Expiry Date (mm/dd/yyyy)*
MM slash DD slash YYYY
Date of Entry to Canada (mm/dd/yyyy)*
MM slash DD slash YYYY
School Information
Name of School*
School Address (Including province)*
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Allianz International Students Insurance Quote Request Form

Allianz International Students Insurance – Quote Request Form

To be eligible for coverage, you must:

Applicant Information

Applicant 1

Applicant 2

Applicant 3

Address in Canada

Coverage Dates

School Information