Application for International Student Health and Hospitalization Insurance
Applicant Information
The applicant must personally complete the application. Your personal information is collected for the purpose of providing you with insurance services, claims analysis and payments. RSA Privacy Policy. For Privacy Information, please see www.rsagroup.ca, or call us at 1-800-716-4339.

Eligibility Requirements
To be eligible for coverage under this plan:
1.
The applicant must:
a)
be 65 years old or less; and
b)
not be eligible for a provincial or territorial government health insurance plan in Canada; and
2.
The applicant must:
a)
be a student attending a recognized Canadian institution of learning (in the event of a claim, your proof of enrolment may be requested); or
b)
be a student completing post-doctorate research in a recognized Canadian institution of learning.
3.
The applicant's spouse and child(ren) may be covered if the appropriate premium is paid.

View Rate Schedule (pdf)
(Rates for school year 2013 - 2014
Effective August 1, 2013)

Title:
*Last Name:   *First Name:  
Date of Arrival in Canada:
Date of birth:
 
Attended School Name in Canada:  
Full address in home Country:
Address in Canada
Address Mandatory
Number, Street: 
Apt:  City: 
Province:  Postal Code : 
*Phone:  Fax: 
*Email: 
You will receive a copy of your application.
Dependent Information
Dependents' Date of Arrival in Canada: 

If you need more space to add children please use the "Notes/Comments" box at the bottom of this page.

Last name First Name Date of Birth:
Spouse:
Child:
Child:
Child:
Child:
Insurance Period and Payment Mode
Desired Effective Date:  Number of months:
(max.12 months)
Certified Cheque/Money Order (Please make cheque payable to etfs)
Your cheque or money order must arrive by mail at RSA within the 10 business days following the submission of your on-line application. If we do not receive your payment in this delay, your application will be refused.
Visa
Master Card
American Express

Credit Card Number: 

Expiry Date: 

Cardholder Name:
Notes/Comments
Medical Authorization and Declaration
By submitting this application:
  • I confirm that I meet all of the Eligibility Requirements described above.

  • I understand that I must purchase the policy within 30 days from the earliest of the date of my arrival in Canada or the date of my enrolment at a recognized Canadian institution of learning. If I am presently insured under an insurance policy administered by RSA, I must pay the insurance premium prior to the termination date of my existing policy. If I do not satisfy the above condition, I understand that I will not be covered for a sickness occuring during the first 30 days of insurance.

  • I understand that Royal & Sun Alliance Insurance Company of Canada and Global Excel Management Inc. may investigate my claim. By submitting this application, I also hereby direct and authorize any physician, health care practitioner, hospital or other medical care facility, pharmacy, the Ministry of Health or any other person who has attended and examined me or who has knowledge or records of me or my health, to furnish to RSA and to Global Excel Management Inc. any or all information with respect to my sickness, injury, medical history, consultations, medicines or treatment and copies of all hospital or medical records for the purpose of investigating my claim.

You must consent to the medical authorization by checking "I agree" in order to purchase this insurance.
I agree
IMPORTANT
Please note that this is an insurance application. You have no insurance coverage until RSA sends written confirmation of coverage.
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