Parksville Insurance Service - International Student Medical Insurance Plan Application Form

International Student Insurance Plan Application Form V1.1
International Student Medical Insurance Plan Eligibility Requirements
	1. You must be a student of foreign nationality. 2. You must be enrolled full-time in a recognized institution of learning. 3. You must not be a Canadian citizen or landed immigrant.
Name:
	Surname	Given Names
Address in Canada:
City:		Province:
Postal Code:		Sex: Male - Female
Day Phone:( ) -		Fax: ( ) -
Email:		Date of Birth: Y M D
Effective Date of Insurance: Y M D		Expiry Date of Insurance: Y M D

Name of Teaching Institution:		Next of Kin:

Address:		Phone:( ) -

Country of permanent residence:
Treating or family physician in country of permanent residence:
Payment of this policy indicates my understanding and acceptance of the following conditions:
	Coverage will become effective on my arrival in Canada provided I applied on or before that date, otherwise coverage will be effective on the date my application is accepted by Parksville Insurance Service. I have not seen a doctor nor been to hospital since my arrival in Canada. I am in good health at the present time. I certify all the above information is true and correct.
Today's Date: Y M D
Arrival Date in Canada: Y M D
PLEASE NOTE: There is a 48-hour waiting period on Sickness.

Estimated Premium:		$
Paid By:
	Cheque Mailed	Number: Exp: /
	Charge Mastercard
	Charge Visa