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 - $2.5 a day
Up to 100,000 - $3.5 a day
Up to 150,000 - $4.5 a day
Up to 300,000 - $7 a day

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