Submission of this form will result in a no obligation quote to be sent to the email address you provide within 72 hours. Your quote will include the premium amount and the insurance policy wording. A secure online payment authorization is available to pay online.

After receiving your submission the representatives at Lifestyle Financial will contact you directly to answer any questions you may have.

If you have any questions please call 250 542 8577 or email: travel@lifestylefinancial.ca

1 - About You

First name Last Name Gender Male Female Birth Month January February March April May June July August September October November December Birth Day 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 Birth Year 2005 2004 2003 2002 2001 2000 1999 1998 1997 1996 1995 1994 1993 1992 1991 1990 1989 1988 1987 1986 1985 1984 1983 1982 1981 1980 1979 1978 1977 1976 1975 1974 1973 1972 1971 1970 1969 1968 1967 1966 1965 1964 1963 1962 1961 1960 1959 1958 1957 1956 1955 1954 1953 1952 1951 1950 1949 1948 1947 1946 1945 1944 1943 1942 1941 1940 1939 1938 1937 1936 1935 1934 1933 1932 1931 1930 1929 1928 1927 1926 1925 1924 1923 1922 1921 1920 1919 1918 1917 1916 1915 1914 1913 1912 1911 1910

2 - Contact Information

Address Address Line 2 City Province/State Postal/Zip Code Country Phone Email

3 - Trip Details

Trip Start Date - for Visitor to Canada Emergency Medical Coverage, this is the date you enter Canada Start Month January February March April May June July August September October November December Start Day 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 Start Year 2012 2013 2014 2015 2016 2017 Trip End Date - for Visitor to Canada Emergency Medical Coverage, this is the date you exit Canada End Month January February March April May June July August September October November December End Day 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 End Year 2012 2013 2014 2015 2016 2017 Amount Paid in Canadian Dollars - Purchased, prepaid travel arrangements, can include flights, tour cost, accommodations, etc. $100 $200 $300 $400 $500 $600 $700 $800 $900 $1000 $1100 $1200 $1300 $1400 $1500 $1600 $1700 $1800 $1900 $2000 $2100 $2200 $2300 $2400 $2500 $2600 $2700 $2800 $2900 $3000 $3100 $3200 $3300 $3400 $3500 $3600 $3700 $3800 $3900 $4000 $4100 $4200 $4300 $4400 $4500 $4600 $4700 $4800 $4900 $5000 $5100 $5200 $5300 $5400 $5500 $5600 $5700 $5800 $5900 $6000 $6100 $6100 $6200 $6300 $6400 $6500 $6600 $6700 $6800 $6900 $7000 $7100 $7200 $7300 $7400 $7500 $7600 $7700 $7800 $7900 $8000 $8100 $8200 $8300 $8400 $8500 $8600 $8700 $8800 $8900 $9000 $9100 $9200 $9300 $9400 $9500 $9600 $9700 $9800 $9900 $10000 $10100 $10200 $10300 $10400 $10500 $10600 $10700 $10800 $10900 $11000 $11100 $11200 $11300 $11400 $11500 $11600 $11700 $11800 $11900 $12000 $12100 $12200 $12300 $12400 $12500 $12600 $12700 $12800 $12900 $13000 $13100 $13200 $13300 $13400 $13500 $13600 $13700 $13800 $13900 $14000 $14100 $14200 $14300 $14400 $14500 $14600 $14700 $14800 $14900 $15000 $15100 $15200 $15300 $15400 $15500 $15600 $15700 $15800 $15900 $16000 $16100 $16100 $16200 $16300 $16400 $16500 $16600 $16700 $16800 $16900 $17000 $17100 $17200 $17300 $17400 $17500 $17600 $17700 $17800 $17900 $18000 $18100 $18100 $18200 $18300 $18400 $18500 $18600 $18700 $18800 $18900 $18000 $19100 $19100 $19200 $19300 $19400 $19500 $19600 $19700 $19800 $19900 $20000

Deposit

Full Payment

4 - Additional Travelers

Additional travelers must reside at the same address and be a dependant of the primary traveler. The trip dates must coincide with the primary traveler indicated in section 1. The trip amount for additional travelers may vary based on the individual package cost.

Additional Traveler 1

First Name Last Name Gender Male Female Relationship Brother Child Grandparent Parent Sister Spouse Other Birth Month January February March April May June July August September October November December Birth Day 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 Birth Year 2010 2009 2008 2007 2006 2005 2004 2003 2002 2001 2000 1999 1998 1997 1996 1995 1994 1993 1992 1991 1990 1989 1988 1987 1986 1985 1984 1983 1982 1981 1980 1979 1978 1977 1976 1975 1974 1973 1972 1971 1970 1969 1968 1967 1966 1965 1964 1963 1962 1961 1960 1959 1958 1957 1956 1955 1954 1953 1952 1951 1950 1949 1948 1947 1946 1945 1944 1943 1942 1941 1940 1939 1938 1937 1936 1935 1934 1933 1932 1931 1930 1929 1928 1927 1926 1925 1924 1923 1922 1921 1920 1919 1918 1917 1916 1915 1914 1913 1912 1911 1910 Amount Paid in Canadian Dollars - Purchased, prepaid travel arrangements, can include flights, tour cost, accommodations, etc. $100 $200 $300 $400 $500 $600 $700 $800 $900 $1000 $1100 $1200 $1300 $1400 $1500 $1600 $1700 $1800 $1900 $2000 $2100 $2200 $2300 $2400 $2500 $2600 $2700 $2800 $2900 $3000 $3100 $3200 $3300 $3400 $3500 $3600 $3700 $3800 $3900 $4000 $4100 $4200 $4300 $4400 $4500 $4600 $4700 $4800 $4900 $5000 $5100 $5200 $5300 $5400 $5500 $5600 $5700 $5800 $5900 $6000 $6100 $6100 $6200 $6300 $6400 $6500 $6600 $6700 $6800 $6900 $7000 $7100 $7200 $7300 $7400 $7500 $7600 $7700 $7800 $7900 $8000 $8100 $8200 $8300 $8400 $8500 $8600 $8700 $8800 $8900 $9000 $9100 $9200 $9300 $9400 $9500 $9600 $9700 $9800 $9900 $10000 $10100 $10200 $10300 $10400 $10500 $10600 $10700 $10800 $10900 $11000 $11100 $11200 $11300 $11400 $11500 $11600 $11700 $11800 $11900 $12000 $12100 $12200 $12300 $12400 $12500 $12600 $12700 $12800 $12900 $13000 $13100 $13200 $13300 $13400 $13500 $13600 $13700 $13800 $13900 $14000 $14100 $14200 $14300 $14400 $14500 $14600 $14700 $14800 $14900 $15000 $15100 $15200 $15300 $15400 $15500 $15600 $15700 $15800 $15900 $16000 $16100 $16100 $16200 $16300 $16400 $16500 $16600 $16700 $16800 $16900 $17000 $17100 $17200 $17300 $17400 $17500 $17600 $17700 $17800 $17900 $18000 $18100 $18100 $18200 $18300 $18400 $18500 $18600 $18700 $18800 $18900 $18000 $19100 $19100 $19200 $19300 $19400 $19500 $19600 $19700 $19800 $19900 $20000

Deposit

Full Payment

Additional Traveler 2

First Name Last Name Gender Male Female Relationship Brother Child Grandparent Parent Sister Spouse Other Birth Month January February March April May June July August September October November December Birth Day 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 Birth Year 2010 2009 2008 2007 2006 2005 2004 2003 2002 2001 2000 1999 1998 1997 1996 1995 1994 1993 1992 1991 1990 1989 1988 1987 1986 1985 1984 1983 1982 1981 1980 1979 1978 1977 1976 1975 1974 1973 1972 1971 1970 1969 1968 1967 1966 1965 1964 1963 1962 1961 1960 1959 1958 1957 1956 1955 1954 1953 1952 1951 1950 1949 1948 1947 1946 1945 1944 1943 1942 1941 1940 1939 1938 1937 1936 1935 1934 1933 1932 1931 1930 1929 1928 1927 1926 1925 1924 1923 1922 1921 1920 1919 1918 1917 1916 1915 1914 1913 1912 1911 1910 Amount Paid in Canadian Dollars - Purchased, prepaid travel arrangements, can include flights, tour cost, accommodations, etc. $100 $200 $300 $400 $500 $600 $700 $800 $900 $1000 $1100 $1200 $1300 $1400 $1500 $1600 $1700 $1800 $1900 $2000 $2100 $2200 $2300 $2400 $2500 $2600 $2700 $2800 $2900 $3000 $3100 $3200 $3300 $3400 $3500 $3600 $3700 $3800 $3900 $4000 $4100 $4200 $4300 $4400 $4500 $4600 $4700 $4800 $4900 $5000 $5100 $5200 $5300 $5400 $5500 $5600 $5700 $5800 $5900 $6000 $6100 $6100 $6200 $6300 $6400 $6500 $6600 $6700 $6800 $6900 $7000 $7100 $7200 $7300 $7400 $7500 $7600 $7700 $7800 $7900 $8000 $8100 $8200 $8300 $8400 $8500 $8600 $8700 $8800 $8900 $9000 $9100 $9200 $9300 $9400 $9500 $9600 $9700 $9800 $9900 $10000 $10100 $10200 $10300 $10400 $10500 $10600 $10700 $10800 $10900 $11000 $11100 $11200 $11300 $11400 $11500 $11600 $11700 $11800 $11900 $12000 $12100 $12200 $12300 $12400 $12500 $12600 $12700 $12800 $12900 $13000 $13100 $13200 $13300 $13400 $13500 $13600 $13700 $13800 $13900 $14000 $14100 $14200 $14300 $14400 $14500 $14600 $14700 $14800 $14900 $15000 $15100 $15200 $15300 $15400 $15500 $15600 $15700 $15800 $15900 $16000 $16100 $16100 $16200 $16300 $16400 $16500 $16600 $16700 $16800 $16900 $17000 $17100 $17200 $17300 $17400 $17500 $17600 $17700 $17800 $17900 $18000 $18100 $18100 $18200 $18300 $18400 $18500 $18600 $18700 $18800 $18900 $18000 $19100 $19100 $19200 $19300 $19400 $19500 $19600 $19700 $19800 $19900 $20000

Deposit

Full Payment

Additional Traveler 3

First Name Last Name Gender Male Female Relationship Brother Child Grandparent Parent Sister Spouse Other Birth Month January February March April May June July August September October November December Birth Day 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 Birth Year 2010 2009 2008 2007 2006 2005 2004 2003 2002 2001 2000 1999 1998 1997 1996 1995 1994 1993 1992 1991 1990 1989 1988 1987 1986 1985 1984 1983 1982 1981 1980 1979 1978 1977 1976 1975 1974 1973 1972 1971 1970 1969 1968 1967 1966 1965 1964 1963 1962 1961 1960 1959 1958 1957 1956 1955 1954 1953 1952 1951 1950 1949 1948 1947 1946 1945 1944 1943 1942 1941 1940 1939 1938 1937 1936 1935 1934 1933 1932 1931 1930 1929 1928 1927 1926 1925 1924 1923 1922 1921 1920 1919 1918 1917 1916 1915 1914 1913 1912 1911 1910 Amount Paid in Canadian Dollars - Purchased, prepaid travel arrangements, can include flights, tour cost, accommodations, etc. $100 $200 $300 $400 $500 $600 $700 $800 $900 $1000 $1100 $1200 $1300 $1400 $1500 $1600 $1700 $1800 $1900 $2000 $2100 $2200 $2300 $2400 $2500 $2600 $2700 $2800 $2900 $3000 $3100 $3200 $3300 $3400 $3500 $3600 $3700 $3800 $3900 $4000 $4100 $4200 $4300 $4400 $4500 $4600 $4700 $4800 $4900 $5000 $5100 $5200 $5300 $5400 $5500 $5600 $5700 $5800 $5900 $6000 $6100 $6100 $6200 $6300 $6400 $6500 $6600 $6700 $6800 $6900 $7000 $7100 $7200 $7300 $7400 $7500 $7600 $7700 $7800 $7900 $8000 $8100 $8200 $8300 $8400 $8500 $8600 $8700 $8800 $8900 $9000 $9100 $9200 $9300 $9400 $9500 $9600 $9700 $9800 $9900 $10000 $10100 $10200 $10300 $10400 $10500 $10600 $10700 $10800 $10900 $11000 $11100 $11200 $11300 $11400 $11500 $11600 $11700 $11800 $11900 $12000 $12100 $12200 $12300 $12400 $12500 $12600 $12700 $12800 $12900 $13000 $13100 $13200 $13300 $13400 $13500 $13600 $13700 $13800 $13900 $14000 $14100 $14200 $14300 $14400 $14500 $14600 $14700 $14800 $14900 $15000 $15100 $15200 $15300 $15400 $15500 $15600 $15700 $15800 $15900 $16000 $16100 $16100 $16200 $16300 $16400 $16500 $16600 $16700 $16800 $16900 $17000 $17100 $17200 $17300 $17400 $17500 $17600 $17700 $17800 $17900 $18000 $18100 $18100 $18200 $18300 $18400 $18500 $18600 $18700 $18800 $18900 $18000 $19100 $19100 $19200 $19300 $19400 $19500 $19600 $19700 $19800 $19900 $20000

Deposit

Full Payment

Additional Traveler 4

First Name Last Name Gender Male Female Relationship Brother Child Grandparent Parent Sister Spouse Other Birth Month January February March April May June July August September October November December Birth Day 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 Birth Year 2010 2009 2008 2007 2006 2005 2004 2003 2002 2001 2000 1999 1998 1997 1996 1995 1994 1993 1992 1991 1990 1989 1988 1987 1986 1985 1984 1983 1982 1981 1980 1979 1978 1977 1976 1975 1974 1973 1972 1971 1970 1969 1968 1967 1966 1965 1964 1963 1962 1961 1960 1959 1958 1957 1956 1955 1954 1953 1952 1951 1950 1949 1948 1947 1946 1945 1944 1943 1942 1941 1940 1939 1938 1937 1936 1935 1934 1933 1932 1931 1930 1929 1928 1927 1926 1925 1924 1923 1922 1921 1920 1919 1918 1917 1916 1915 1914 1913 1912 1911 1910 Amount Paid in Canadian Dollars - Purchased, prepaid travel arrangements, can include flights, tour cost, accommodations, etc. $100 $200 $300 $400 $500 $600 $700 $800 $900 $1000 $1100 $1200 $1300 $1400 $1500 $1600 $1700 $1800 $1900 $2000 $2100 $2200 $2300 $2400 $2500 $2600 $2700 $2800 $2900 $3000 $3100 $3200 $3300 $3400 $3500 $3600 $3700 $3800 $3900 $4000 $4100 $4200 $4300 $4400 $4500 $4600 $4700 $4800 $4900 $5000 $5100 $5200 $5300 $5400 $5500 $5600 $5700 $5800 $5900 $6000 $6100 $6100 $6200 $6300 $6400 $6500 $6600 $6700 $6800 $6900 $7000 $7100 $7200 $7300 $7400 $7500 $7600 $7700 $7800 $7900 $8000 $8100 $8200 $8300 $8400 $8500 $8600 $8700 $8800 $8900 $9000 $9100 $9200 $9300 $9400 $9500 $9600 $9700 $9800 $9900 $10000 $10100 $10200 $10300 $10400 $10500 $10600 $10700 $10800 $10900 $11000 $11100 $11200 $11300 $11400 $11500 $11600 $11700 $11800 $11900 $12000 $12100 $12200 $12300 $12400 $12500 $12600 $12700 $12800 $12900 $13000 $13100 $13200 $13300 $13400 $13500 $13600 $13700 $13800 $13900 $14000 $14100 $14200 $14300 $14400 $14500 $14600 $14700 $14800 $14900 $15000 $15100 $15200 $15300 $15400 $15500 $15600 $15700 $15800 $15900 $16000 $16100 $16100 $16200 $16300 $16400 $16500 $16600 $16700 $16800 $16900 $17000 $17100 $17200 $17300 $17400 $17500 $17600 $17700 $17800 $17900 $18000 $18100 $18100 $18200 $18300 $18400 $18500 $18600 $18700 $18800 $18900 $18000 $19100 $19100 $19200 $19300 $19400 $19500 $19600 $19700 $19800 $19900 $20000

Deposit

Full Payment

5 - Comments, questions, special requests

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6 - Verification

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