Travel Insurance Canada provided by Lutz Financial Services

Damdochax River Lodge

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, the insurance policy wording and a secure online payment authorization to confirm your purchase should you choose to do so.

For travelers wishing to insure an amount higher than $12,500 CAD a Medical Questionnaire or Health Declaration will need to be submitted prior to receiving a premium quote. The representatives at Lutz Financial will contact you directly to explain this process after receiving your submission.

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

1 - About You First name Last Name Gender Birth Month Birth Day Birth Year

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 Start Day Start Year Trip End Date - for Visitor to Canada Emergency Medical Coverage, this is the date you exit Canada End Month End Day End Year Value of Trip in Canadian Dollars - Purchased, prepaid travel arrangements, can include flights, tour cost, accommodations, etc. Deposit in Canadian Dollars Date Deposit Paid Deposit Month Deposit Day Deposit Year Balance Due Date Balance Due Month Balance Due Day Balance Due Year

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 Relationship Birth Month Birth Day Birth Year Value of Trip in Canadian Dollars - Purchased, prepaid travel arrangements, can include flights, tour cost, accommodations, etc. Deposit in Canadian Dollars Date Deposit Paid Deposit Month Deposit Day Deposit Year Balance Due Date Balance Due Month Balance Due Day Balance Due Year

Additional Traveler 2 First Name Last Name Gender Relationship Birth Month Birth Day Birth Year Value of Trip in Canadian Dollars - Purchased, prepaid travel arrangements, can include flights, tour cost, accommodations, etc. Deposit in Canadian Dollars Date Deposit Paid Deposit Month Deposit Day Deposit Year Balance Due Date Balance Due Month Balance Due Day Balance Due Year

Additional Traveler 3 First Name Last Name Gender Relationship Birth Month Birth Day Birth Year Value of Trip in Canadian Dollars - Purchased, prepaid travel arrangements, can include flights, tour cost, accommodations, etc. Deposit in Canadian Dollars Date Deposit Paid Deposit Month Deposit Day Deposit Year Balance Due Date Balance Due Month Balance Due Day Balance Due Year

Additional Traveler 4 First Name Last Name Gender Relationship Birth Month Birth Day Birth Year Value of Trip in Canadian Dollars - Purchased, prepaid travel arrangements, can include flights, tour cost, accommodations, etc. Deposit in Canadian Dollars Date Deposit Paid Deposit Month Deposit Day Deposit Year Balance Due Date Balance Due Month Balance Due Day Balance Due Year

5 - Verification

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