International Alumni Buy Now Form

Please complete this form to request to purchase the Student VIP International Alumni Health Plan. Once the form is submitted an agent will contact you.

Submitting this form does not mean you have purchased coverage or are insured. It is just the request to start your application.

Name * First Last
Date of birth * / MM / DD YYYY
Phone * - ### - ### ####
University you are graduating from *
Email *
Address *
Street Address Address Line 2 City State / Province / Region Postal / Zip Code Country
Home Country (Country you came to Canada from) *
Coverage Start Date * / MM / DD YYYY
Coverage End Date * / MM / DD YYYY
Do you require family coverage? *
Yes No
If yes, please list the name, relationship to you and date of birth of each dependent (Spouses & Children only) First Last
Date of birth / MM / DD YYYY
Relationship to you
Name First Last
Date / MM / DD YYYY
Relationship to you
I understand that by completing this form I do not have active or in force health insurance. I understand that only when my application and payment are completed by telephone with a licensed agent and I am emailed confirmation of my policy that my coverage will be in force. I agree to be contacted by telephone or email for the sole purpose of completing my application for coverage.
I agree and understand to the terms and conditions above. *
Draw your signature into the box below. *

Clear