Insurance Application for Non-Canadians

Parent's Name*

First Last

Child's Name*

First Last

(person being insured)

Email*

Phone*

Home Address*

Street Address City State / Province / Region ZIP / Postal Code Country

Date of Birth*

Arrival Date*

Departure Date*

Place of Origin*

Destination: Port Carling, Ontario

Choose your coverage: (Please note: Prices may vary slightly based on age)*

Up to 50,000
Up to 100,000
Up to 150,000
Up to 300,000

Your credit card on camps file will be charged based on your selection above.

Does your child have any pre existing physical or mental conditions?*

Yes
No

Please note: If you select 'no', if any illness or emergency occurs due to any pre existing conditions, your claims may be denied. If you have any questions regarding whether a pre existing condition needs to be listed, please call: 647 709 9254

Please specify:*

Credit Card Information

Your card will be billed the insurance company. It will appear on your statment as "Travel Insurance".

Name on card*

First Last

Card Type*

Visa
MasterCard
American Express

Card Number*

Expiry Date*

Please use MM/YY format

CVV*