Member Contact Information Form

McGill Comprehensive Travel Coverage - Contact Information and Quotation Request Form
Please complete the form below to receive coverage information or a quotation *required fields

Trip and Contact Information

*Full Name(s):

*Date of Birth:

(day) (month) (year) (for cost comparison)

*Date of Departure:

(day) (month) (year)

*Date of Return:

(day) (month) (year)

*Destination:

*Do you have existing travel coverage? Yes No If so, how many days?

*Are you looking for: single trip or multi-trip policy? Single Trip Policy Multi-Trip Policy

If you are looking for Multi-Trip coverage, please indicate the maximum number of days that you will be away:

Address 1:

Address 2:

City:

Province:

(Select from list)

Postal Code:

*e-mail:

Telephone:

(select call time below)

fax:

Questions or Comments:

What is the best time to contact you? (check one from each column if you would like us to contact you)

Morning	Weekday
Afternoon	Weekend
Evening

Thank you!