旅行医疗保险By phone(电话)申请时，申请人也可在线填写以下预申请表发送给我们，或将预申请表填写打印填写后传真给我们，再由我们回电给申请人做详细解释和最后确定。

1、您的姓名(Your Name): _______________________________________
2、电话(Phone No.): (____)____________________
3、电子信箱(Email): (____)____________________

4、受保人姓名及出生日期，请按姓、名、日、月、年顺序
　(Insured person's name, D.O.B.; in order of surname, given name & dd/mm/yy):
1) 姓(Surname):_____________名(G.Name):______________________;　日(DD):____月(MM):___年(YY):______;
2) 姓(Surname):_____________名(G.Name):______________________;　日(DD):____月(MM):___年(YY):______;
3) 姓(Surname):_____________名(G.Name):______________________;　日(DD):____月(MM):___年(YY):______;
4) 姓(Surname):_____________名(G.Name):______________________;　日(DD):____月(MM):___年(YY):______;

5、加拿大境内联系地址 (Address in Canada)：
　　_________________________________________________
　　_________________________________________________
　　_________________________________________________

6、旅行开始日期(Leaving Date): 日(day)_____月(Month)____年(Year)______;
7、受保起始日期 (Effective Date): 日(day)_____月(Month)____年(Year)______;
8、受保截止日期 (Expiring Date): 日(day)_____月(Month)____年(Year)______;

9、最高受保额 (Coverage, 加元):
　　[ ]$5000; [ ]$15000; [ ]$25000; [ ]$50,000; [ ]$100,000

10、附言 (Your message):