Muskoka Insurance - Cottage Insurance - Hudson Henderson Insurance Brokers

Scolorship Athlete Health/Travel Insurance Application

full name
date of birth
address
city
province
postal code
telephone
Departure City
Destination
Beneficiary
Policy Number
Aplication Date
Effective Date
Number of Days Covered
Expiry Date
Number of people Being Insured
email address

I hereby authorize release of any information, including medical records, that are required to process a claim filed under this policy, in conjunction with the purchase of this policy to Travel Guard Canada, or its representative.

The signatory confirms that every person named on this application is in good health and knows of no reason to seek medical attention. Applicants are aware that if they have any condition affecting their health, that claims relating to this condition may be excluded under this policy.