Hudson Henderson and W.L Edwards Insurance

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

Credit Card info	Visa Mastercard Amex Diners
Card Number
Expiry Date	/ Auth. No.
Name

Group Packages - Check the Sports you are participating in.

Class 1
10 Month Rate
$575.83

Class 2
10 Month Rate
$606.03

Class 3
10 Month Rate
$636.52

Class4
10 Month Rate
$686.22

Badminton Bowling Curling Dancing Golf Running Swimming Tennis Ultimate Frisbee Volleyball	Baseball Basketball Bicycling Canoeing Fishing Gymnastics Rollerblading Sailing Soccer Triathalon	Archery Football Hockey Horse Riding Kayaking Lacrosse Rock Climbing Skiing Snowboarding Water Skiing Windsurfing	Gliding Hunting Martial Arts Parachuting Rugby Surfing Wrestling

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.