Application Form For Visitors To Canada
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1Johnson Fu Insurance Agency Inc.
128-6061 No. 3 Road, Richmond, BC, V6Y 2B2
Phone: 604-232-0896 Fax: 604-232-0897
Email:
Application form for Visitors to Canada
st
_____JF Premier
_____TU
_____TIC
_____ETFS
_____21
Century
Insurance is administered by North American Air Travel Insurance Agents Ltd. d.b.a. Travel Underwriters, a licensed insurance broker.
Policy #: ________________
11th floor – 6081 No. 3 Road, Richmond, BC, Canada V6Y 2B2. Insurance is underwritten by
Industrial Alliance Pacific Insurance and Financial Services Inc.
Name Insured (
)
Please print
1. First Name: ___________________________ Last Name: ___________________ Date of Birth
__________ Age: ____ Gender: F / M
(MM/DD/YY)
Other insured
(for additional insured, attached a separate page.)
2. First Name: ___________________________ Last Name: ___________________ Date of Birth
__________ Age: ____ Gender: F / M
(MM/DD/YY)
3. First Name: ___________________________ Last Name: ___________________ Date of Birth
__________ Age: ____ Gender: F / M
(MM/DD/YY)
4. First Name: ___________________________ Last Name: ___________________ Date of Birth
__________ Age: ____ Gender: F / M
(MM/DD/YY)
5. First Name: ___________________________ Last Name: ___________________ Date of Birth
__________ Age: ____ Gender: F / M
(MM/DD/YY)
Canadian Address: __________________________________________________________________________________________________
Street
City
Province
Postal Code
Phone Number: ________________________________________Country of Origin: ___________________________________________
): ___________________Effective Date
): _________________ Expiry Date (
__________________
Arrival Date
(MM/DD/YY
(MM/DD/YY
MM/DD/YY):
): _______________________ Number of Coverage Day: _______________________________
Application Date
(MM/DD/YY
For renewals only – Previous policy #: ___________________
I hereby apply for coverage and understand that coverage will become effective
on my arrival date in Canada provided I apply on or before that date, otherwise
:
Coverage Option
$20,000
$30,000
coverage will be effective on the date my application is accepted by the Insurer, or
their authorized agent.
$50,000
$100,000
I have not seen a doctor nor been to hospital since my arrival in Canada. I am in
Single: # of Days ____ x $ ________ = $ _________
good health at the present time and have no intention of claiming as of today’s
date and time.
Family: # of Days ____ x $ ________ = $ _________
I hereby certify all the above information is true and accurate.
Total Premium: $ ______________
By signing below, I agree that I have read the coverage and contents of the
information concerning my insurance plan provided to me by Johnson Fu
Paid by:
Visa
Mastercard
AE
Insurance Agency Inc. (JF) and that I understand the contents and details of this
information. I further agree and understand that I will direct any inquiries I have
Credit Card #:
regarding insurance to JF and its licensed agents.
I understand that _____________________ will receive a referral fee for this
transaction.
Cardholder Name: _____________________________________
________________________________
Signature of Cardholder: _________________________________
Applicant’s Signature
Expiry Date
): ____________
________________________________
(MM/DD/YY
Date
Visitor_App_Eng_090527
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