Allianz Youth Package for Canadian Travellers – 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 Information
Applicant
Applicant: First Name*
Applicant: Last Name*
Applicant: Date of Birth (mm/dd/yyyy)*
MM slash DD slash YYYY
Applicant: Gender*
- Male
- Female
Do you have a traveling companion?*
If 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 information
Address in Canada
Address*
Address Line 1 * Address Line 2 City * Province * Postal Code *
Telephone Number*
E-mail Address*
Enter Email Confirm Email
Coverage Dates
Is this an extension, top up, or after departure policy?
- Yes
- No
Departure Date (mm/dd/yyyy)*
MM slash DD slash YYYY
Effective Date (mm/dd/yyyy)*
MM slash DD slash YYYY
Please enter the effective date at least 5 days after today.
Departure Date (mm/dd/yyyy)*
MM slash DD slash YYYY
Please enter the effective date at least 5 days after today.
Return / Expiry Date (mm/dd/yyyy)*
MM slash DD slash YYYY
Coverage Selection
Primary 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.
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Allianz Youth Package Quote Request Form

Allianz Youth Package for Canadian Travellers – Quote Request Form

To be eligible for coverage, all of the following conditions must be met:

Applicant Information

Applicant

Address in Canada

Coverage Dates

Coverage Selection