Please, complete the following form in order to apply for Visitors Insurance from 21st Century Travel Insurance Limited.

You are not eligible for coverage under this policy if:
- you are travelling against the advice of a physician;
- you have been diagnosed with a terminal illness with less than two years to live;
- you have been diagnosed with or received treatment within the last two (2) years for pancreatic, lung, brain, or liver cancer; or any type of cancer that has spread from one part or organ of the body to another (metastatic cancer);
- you have had or are waiting for an organ or bone marrow transplant (excluding corneal transplant);
- you have a kidney condition requiring dialysis;
- you have used home oxygen during the 12 months prior to the date of application; and/or
- you reside in a nursing home, home for the aged, other long term care facility or rehabilitation centre.

Applicants age 55 to 85 who wish to purchase "Enhanced Plan" option must complete the medical declaration on the application to determine eligibility for coverage.

Number of people to be insured:

1 2 3 4 5 6

First Name:

Last Name:

Gender:

Male     Female

Date of Birth:

Other Passengers:
First Name	Last Name	Gender	Date of Birth
		Male Female
Cover STABLE existing medical condition?  Yes  No
Answer the following questions to determine eligibility If unsure how to respond to any question, please consult a physician. Applicant 2 1. In relation to any heart or lung condition, shortness of breath, chest pain, stroke or mini-stroke (Transient Ischemic Attack/TIA), have you within the last 12 months:     a) been newly diagnosed,     b) been prescribed any new medication or any change in dosage, frequency or type of medication,     c) had any new or any change in treatment (including investigation or testing),     d) been referred to a specialist physician for investigation or testing, or     e) been hospitalized or been seen in the emergency department of a hospital?  Yes  No 2. Have you:     a) had a heart bypass, heart valve surgery or angioplasty more than 10 years ago (use the date of the most recent procedure), or     b) been diagnosed with a heart valve disorder but not yet had heart valve surgery?  Yes  No 3. Have you ever been diagnosed with congestive heart failure?  Yes  No 4. Within the past 12 months have you:     a) been treated for and/or been diagnosed with internal bleeding; or     b) been admitted to hospital for a gastrointestinal disease or disorder; or     c) received treatment (including investigation or testing) for any cancer (except basal cell and squamous cell skin cancer)?  Yes  No 5. Within the past 12 months have you been prescribed or taken any of the following:     a) Lasix or furosemide for any reason;     b) prednisone for any lung condition;     c) medications for both diabetes and a heart condition (answer No if you are medicated for one but not both of these conditions. Medication prescribed solely for the control of blood pressure is not a medication for a heart condition);     d) any form of nitroglycerin for the relief of angina pain (including on an “as needed” basis)?  Yes  No Responses provided by: Relationship to applicant:
		Male Female
		Male Female
		Male Female
		Male Female

Cover STABLE existing medical condition?

 Yes  No

Answer the following questions to determine eligibility If unsure how to respond to any question, please consult a physician.	Applicant 1
1. In relation to any heart or lung condition, shortness of breath, chest pain, stroke or mini-stroke (Transient Ischemic Attack/TIA), have you within the last 12 months:     a) been newly diagnosed,     b) been prescribed any new medication or any change in dosage, frequency or type of medication,     c) had any new or any change in treatment (including investigation or testing),     d) been referred to a specialist physician for investigation or testing, or     e) been hospitalized or been seen in the emergency department of a hospital?	Yes  No
2. Have you:     a) had a heart bypass, heart valve surgery or angioplasty more than 10 years ago (use the date of the most recent procedure), or     b) been diagnosed with a heart valve disorder but not yet had heart valve surgery?	Yes  No
3. Have you ever been diagnosed with congestive heart failure?	Yes  No
4. Within the past 12 months have you:     a) been treated for and/or been diagnosed with internal bleeding; or     b) been admitted to hospital for a gastrointestinal disease or disorder; or     c) received treatment (including investigation or testing) for any cancer (except basal cell and squamous cell skin cancer)?	Yes  No
5. Within the past 12 months have you been prescribed or taken any of the following:     a) Lasix or furosemide for any reason;     b) prednisone for any lung condition;     c) medications for both diabetes and a heart condition (answer No if you are medicated for one but not both of these conditions. Medication prescribed solely for the control of blood pressure is not a medication for a heart condition);     d) any form of nitroglycerin for the relief of angina pain (including on an “as needed” basis)?	Yes  No
Responses provided by: Relationship to applicant:

Arrival Date in Canada:

Country of Origin:

Visitors Type:

New Immigrant Returning Canadian Super Visa Visitor Work or Student Visa Unknown

Sponsor in Canada (optional):

Address in Canada:

City:

Province:

Select province Alberta British Columbia Manitoba New Brunswick Newfoundland and Labrador Northwest Territories Nova Scotia Nunavut Ontario Prince Edward Island Quebec Saskatchewan Yukon Territory

Postal Code:

Phone:

E-mail:

E-mail 2 (optional):

Insurance Start Date:

Insurance End Date:

Deductible:

$0 $100 $250 $500 $1,000 $2,500 $5,000 $10,000

Insurance Benefit:

$15,000 $25,000 $50,000 $100,000 $150,000 $200,000

Total Premium:

 Premium Refunds: Because this insurance is being purchased as a requirement of Citizenship and Immigration Canada to support your Super Visa status, 21st Century cannot cancel this policy prior to your arrival date and refund premium paid without proof of a declined Visa (or death). Requests for refunds due to your early departure from Canada after your arrival date will require proof that you have exited Canada to return to your country of origin. If you cancel this insurance, your policy confirmation cannot be used for any future entries into Canada under your Super Visa. New insurance will need to be purchased before you can enter Canada again. No premium for unused days of your coverage will be refunded if a claim has been reported, paid or denied. If a claim is payable, but has not yet been paid, you may apply to have it withdrawn, subject to a file handling fee of $200 per claim. All refunds are subject to approval by 21st Century. A $25 policy administration fee will be applied to any refund or cancellation.

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