Gold Plan

Application Form

Primary Applicant
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Additional Applicants
Companion 1
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Companion 2
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Companion 3
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Companion 4
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Companion 5
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Coverage Details
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Address in Canada
Legal Guardian/Custodian

If you are under the age of 18, please provide the name of your legal guardian or custodian while studying in Canada.

Beneficiary In Case of Death
Payment Information
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