Travelance | Application Form
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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?
Your arrival date in Canada
Insurance Start Date
Insurance End Date
Do you have a pre-existing medical condition?
Pre-existing/2nd person
Stable period <b>Stable means a pre-existing medical condition that:</b><br><br> 
a) did not require, or was not  recommended for any changes to existing treatment or new treatment;<br>
b) did not become worse during the chosen stability period.<br>
c) did not require a change in type or dosage of medication (if any are being taken by the person to be insured).<br><br>
<i>* Please note that if you are currently taking any medications and/or undergoing continuous treatment, expenses associated with these are not covered under any policy as per ongoing treatment exclusion.</i>
Payment Details
Credit card number
Credit card type:
CVC( CVV ) Code
Valid to:
Card Holder Name


Eligibility Requirements:
To be eligible for the Travelance Essential Plan, each applicant must meet the following conditions:

1) Be older than 14 days old and under 86 years old.
* If you are over 70 years old, the maximum coverage amount is limited to $100,000.
2) You must not have a medical condition due to which a physician has advised you NOT to travel (prior to the start date of this insurance policy).
3) You must NOT have an aneurysm that has not been surgically treated.
4) You must have NEVER been diagnosed with or treated for:
- Congestive heart failure;
- Liver or pancreatic cancer, or any type of metastasized cancer;
- An organ or a bone marrow transplant;
- A kidney condition that requires dialysis therapy;
- Any terminal sickness (with a prognosis of 12 months or less to live).
5) You must NOT require assistance with Normal Daily Activities i.e. bathing, eating, dressing up, etc.
*Please note that this condition does not apply for children under 12 years old.
6) You must NOT have been prescribed or taken oral steroids or home oxygen for the treatment of a lung condition within 12 months before the start date of the insurance policy.
7) You must NOT reside in a nursing, convalescent or assisted living home, hospice care facility or a rehabilitation centre at the time you purchase this insurance policy.
8) During the 12 months immediately prior to the start date of this insurance policy, you have NOT been:
a) Diagnosed with or treated for any 2 (two) conditions from the list below;
b) Admitted to hospital for any 1 (one) condition from the list below.

- Coronary artery disease (including heart attack or angina)
- Valvular heart disease (including stenosis, regurgitation or valve replacement)
- Heart arrhythmia (including atrial flutter, atrial fibrillation, ventricular fibrillation or use of a pacemaker)
- A lung or respiratory condition for which daily medication has been prescribed (including inhalers)
- Diabetes requiring insulin
- Stroke or mini-stroke (TIA)
- Aneurysm Blood clots
- Gastro-intestinal bleed

In case the state of your health changes prior to the Effective Date of your insurance policy and you can no longer meet the eligibility requirements listed above, you must contact us for the subsequent policy cancellation.

Your insurance policy is considered void if you do not meet listed eligibility requirements and the company’s liability is only limited to a refund of the paid premium.

Please read the official Policy Wording - Travelance Essential Policy Wording

Once you fill out the application form and enter payment details click on "Buy Insurance" to complete the purchase. You will receive a confirmation email with your insurance policy shortly after your payment is processed.

Please note that we do not save or store your payment information to ensure its security

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