Travel Insurance Quote Request from JustInCaseInsurance.com

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E-Mail:
daniel.latour@
justincaseinsurance.com

Telephone:
1-514-630-6116

Toll Free Line:
1-888-977-7778

Toll-Free Fax:
1-888-245-5505

Mailing Address:
1250 rue University
P.O. Box 5405
Station "B"
Montreal, Quebec
Canada H3B 4P1

Travel Insurance Quote Request Travel insurance covers medical and accident losses while abroad, and can include trip cancellation coverage, loss of baggage, medical, emergency assistance, and life coverage as well. Your Personal Data:

Your Name:
Street Address:
City:
Province:
Postal Code:
E-Mail (REQUIRED):
E-Mail again for accuracy:
Home Phone:
Work Phone:
Fax (optional):

Marital Status: Single Married	Choose Option: Option 1 = Coverage for any new sickness or new injury only. Option 2 = Coverage for pre-existing medical conditions, along with coverage for any new sickness or newinjury.

Departure Date:	Return Date:

Departure City:	Destination City:

Number of Days Coverage? (Standard number of days covered choices are: 2, 4, 8, 15, 30, 60, or 90 days.)

Any Unusual Activities? (If you will engage in unusual activities such as scuba diving, airplane flying, rock climbing, etc., list them here.)

This best describes my travelling situation: Visitor to Canada with Work Permit Canadian Waiting for Provincial HealthInsurance Canadian Travelling Inside Canada Canadian travelling Outside Canada Visitor in Canada without Provincial HealthInsurance Health Travel Insurance Outside Canada (for Canadians)

Underwriting Information:

Name of Insured:		Birthdate:

Name of Travel Companion #1:		Companion #1 Birthdate:

Name of Travel Companion #2:		Companion #2 Birthdate:

Name of Travel Companion #3:		Companion #3 Birthdate:

Baggage & Peronal Effects Values:		$

Cost of Trip to be Covered?		$

Amount of Life Ins. Desired?		$

Any special Medical Coverage Desired? (You may list dollar amount or type of medical coverage you want):

Reason for Buying Insurance:

Send my quotation via:		E-Mail Fax Regular Mail Call Me by Phone

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We value your input as PRIVATE information. Every step has been taken to insure your privacy, security, and our intent is to release quote information only to you. We will not give your data to ANY other person or group for sales, marketing, or ANY other purposes. By checking the box below you agree to allow our agency to release this information via the method you have chosen, and to release us from any liability should this information be accidentally viewed by others. Our intention is to maintain your complete privacy.

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