International Alumni Buy Now Form

Complete this form to request to purchase the International Alumni Health Plan and our agent will be in contact. If you're lost or need assistance, please contact info@studentvip.ca

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

Are you an international student in Canada who has or plans to conclude their studies at a college, university, or accredited post-secondary institution? *
Yes No
When is or was your last day of class? * / MM / DD YYYY
Your Name * First Last
Date of birth * / MM / DD YYYY
Gender
Male Female Other
What school do you attend?
Address *
Street Address Address Line 2 City State / Province / Region Postal / Zip Code Country
Phone * - ### - ### ####
Your Email *
Do you have a dependant (spouse or child) you wish to add to the plan?
Yes No
Dependant date of birth * / MM / DD YYYY
Coverage Start Date * / MM / DD YYYY
Coverage End Date * / MM / DD YYYY
Additional Comments (Optional)