Medipac encourages all prospective clients to READ and PRINT the travel emergency medical insurance policy before purchasing. Please enter the following information to determine your eligibility.
* First Name:
* Last Name
* Date of Birth (dd/mm/yyyy)
* I would like my 23-day Annual Plan to start on (dd/mm/yyyy) Help 
Help  Discount Authorization Code
* Province of Residence
* Have you purchased a Medipac policy in the past?
Yes No Yes No
* During the 3 YEARS prior to the date of this application, have you smoked cigarettes?
Yes No Yes No
(Fields marked with an asterisk * must be entered)
About SSL Certificates
Medipac Travel Insurance is underwritten by Old Republic Insurance Company of Canada. In Quebec, underwritten by Reliable Life Insurance Company.