MEDIPAC QUICK QUOTE

Dale H.

(Fields marked with an asterisk " * " must be entered)
	Province of Residence:		Select Province Alberta British Columbia Manitoba New Brunswick Newfoundland Northwest Territories Nova Scotia Nunavut Ontario P.E.I. Quebec Saskatchewan Yukon Territories
*	Trip Length Applied for in Days		Select Trip Length Up to 3 Days 4 - 6 7 - 9 10 - 12 13 - 15 16 - 18 19 - 21 22 - 24 25 - 27 28 - 30 31 - 33 34 - 36 37 - 40 41 - 50 51 - 60 61 - 66 67 - 75 76 - 82 83 - 90 91 - 96 97 - 105 106 - 112 113 - 120 121 - 126 127 - 135 136 - 142 143 - 150 151 - 156 157 - 165 166 - 175 176 - 183 184 - 190 ON & NF 191 - 200 ON & NF 201 - 212 ON & NF
	I am a Superannuate and I request that my policy be issued with a deductible of CDN$500,000 for the first 40 days of my trip. Help
	I request my policy be issued with a deductible of CDN$100,000 for the first 40 days of my trip.
	Top Up Coverage Help
	Yes    During the 3 YEARS prior to the date of this application, have you smoked cigarettes? No		I am applying for the Annual Add-on Help
*	Plan Type Help		Preferred Plus Preferred Standard
*	Deductible Help		Select Plan Type!
*	Age at Departure		Select Age Up to 55 56 to 60 61 to 65 66 to 70 71 to 75 76 to 79 80 to 85 86 Plus
	Single Trip Rate:
	SUBTRACT Discount: Select Discount! 1% 2% 3% 4% 5% 6% 7% 8% 9% 10% 11% 12% 13% 14% 15% 16% 17% 18% 19% 20%
	Subtotal:
	ADD Annual Add-on Rate (if applicable):
	Rate subtotal:
	ADD 10% if taking a $0 Deductible:
	Subtotal:
	ADD 15% if you have smoked cigarettes in the 3 years prior to the date of this application:
	ADD $20 Top-Up fee or SUBTRACT Federal Superannuate Credit (if applicable):
	Total Premium: