Allianz Global Assistance | Application Form
Your application form is being prepared ...
Personal Information
Number of Applicants
Family members:
1st Applicant
First Name
Last Name
Date of Birth:
Contact Information
Country Code
Country of Residence/Citizenship
City (In Canada)
Canadian Street Address
Province or Territory
Name of Beneficiary (optional)
Postal Code
Canadian Phone (optional)
Insurance Parameters
What type of visitor are you?
Arrival date
Insurance Start Date
Insurance End Date
Optional Information
How can we reach you
Person to contact
Best time to reach you
Insurance Advisor
Comments/Special Requests/Questions
Please note that once you submit your application our Insurance Advisors will contact you to confirm the information, answer your questions and complete the purchase. No payment is required at this stage.

Scroll to Top
Need some help?
Our experienced advisers are just a phone call away!
Do you need advice?
Have questions about your medical coverage options? Feel free to leave us a Call Back request and our insurance advisors will get in touch with you within 1 business day!

You can also leave us a message below, so we can find the most suitable solution to your insurance needs by the time we call you!
Need some help?
Support Us!
If you like our service, please like us on Facebook !