Ingle International

To purchase the Advantage Plan fill out the form below. After submitting the form you will be taken to Paypal's website where you can pay for the insurance. After paying for the insurance and clicking the 'Complete Purchase' button you will be returned to this website and your insurance policy will be emailed to the address you enter below.

If your credit card is not approved, or if payment is not received for any reason whatsoever, your coverage will not be in effect. Coverage is not valid until full payment is received.

Applicant

First Name

Last Name

Sex

Date Of Birth--

Email Address

Country Of Permanent Residence

Coverage Details

Effective Date--

Termination Date--

Price N/A

Address in Canada

Address

Address - line 2

City

Province

Postal Code

Phone

Fax

Beneficiary In Case of Death

First Name

Last Name

Address

City

Country

Relationship to insured

Custom Health Plan for International Students