Available to young Canadian travellers. We will reply to you by e-mail within 1 – 2 business day(s). Privacy Policy * Mandatory Field Allianz Youth Package for Canadian Travellers – Quote Request Form Allianz Youth Plan Quote Request Form To be eligible for coverage, all of the following conditions must be met: a) be at least 15 days old and no more than 29 years old; and b) be a Canadian resident(*) and be insured for benefits under a Canadian government health insurance plan during the entire period of coverage; and c) not have been diagnosed with a terminal illness; or d) not have been diagnosed with stage 3 or 4 cancer; or have received treatment for any cancer (other than basal or squamous cell cancer or breast cancer treated only with hormone therapy) in the last 3 months; or e) not require assistance with activities of daily living as the result of a medical condition or state of health. * Canadian resident means a person legally authorized to reside in Canada and who maintains a permanent residence in Canada. Do you confirm that you are eligible to apply? * Eligibility Option Yes No If you choose No, you are not eligible to apply for this coverage.Applicant InformationApplicant Applicant: First Name*Applicant: Last Name*Applicant: Date of Birth (mm/dd/yyyy)* Applicant: Gender* Male Female Do you have a traveling companion?*NoYesIf you travel alone, please choose No.Please let us know about your travel companion’s information. Name, date of birth, gender and relationship to you are required.Traveling companion's informationAddress in CanadaAddress* Address Line 1 * Address Line 2 City * AlbertaBritish ColumbiaManitobaNew BrunswickNewfoundland and LabradorNorthwest TerritoriesNova ScotiaNunavutOntarioPrince Edward IslandQuebecSaskatchewanYukon Province * Postal Code * Telephone Number*E-mail Address* Enter Email Confirm Email Coverage DatesIs this an extension, top up, or after departure policy? Yes No Departure Date (mm/dd/yyyy)* Effective Date (mm/dd/yyyy)* Please enter the effective date at least 5 days after today.Departure Date (mm/dd/yyyy)* Please enter the effective date at least 5 days after today.Return / Expiry Date (mm/dd/yyyy)* Coverage SelectionPrimary Destination Country*If the one of your destinations is the USA, please specify the USA.Total trip cost (CAD)*Please input the prepaid non-refundable travel expenses such as airline tickets and accommodations.CAPTCHA
