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Country of Origin * United States of America (USA) United Kingdom China France Germany Australia Japan Mexico India South Korea Canada Afghanistan Albania Algeria Andorra Angola Anguilla Antigua & Barbuda Argentina Armenia Austria Azerbaijan Bahamas Bahrain Bangladesh Barbados Belarus Belgium Belize Benin Bermuda Bhutan Bolivia Bosnia & Herzegovina Botswana Brazil Brunei Darussalam Bulgaria Burkina Faso Myanmar/Burma Burundi Cambodia Cameroon Cape Verde Cayman Islands Central African Republic Chad Chile Colombia Comoros Congo Costa Rica Croatia Cuba Cyprus Czechia Democratic Republic of the Congo Denmark Djibouti Dominica Dominican Republic Ecuador Egypt El Salvador Equatorial Guinea Eritrea Estonia Ethiopia Fiji Finland French Guiana Gabon Gambia Georgia Ghana Greece Grenada Guadeloupe Guatemala Guinea Guinea-Bissau Guyana Haiti Honduras Hong Kong Hungary Iceland Indonesia Iran Iraq Israel and the Occupied Territories Italy Ivory Coast (Cote d'Ivoire) Jamaica Jordan Kazakhstan Kenya Kosovo Kuwait Kyrgyz Republic (Kyrgyzstan) Laos Latvia Lebanon Lesotho Liberia Libya Liechtenstein Lithuania Luxembourg Republic of Macedonia Madagascar Malawi Malaysia Maldives Mali Malta Martinique Mauritania Mauritius Mayotte Moldova Monaco Mongolia Montenegro Montserrat Morocco Mozambique Namibia Nepal Netherlands New Zealand Nicaragua Niger Nigeria North Korea Norway Oman Pacific Islands Pakistan Panama Papua New Guinea Paraguay Peru Philippines Poland Portugal Puerto Rico Qatar Reunion Romania Russian Federation Rwanda Saint Kitts and Nevis Saint Lucia Saint Vincent's & Grenadines Samoa Sao Tome and Principe Saudi Arabia Senegal Serbia Seychelles Sierra Leone Singapore Slovakia Slovenia Solomon Islands Somalia South Africa South Sudan Spain Sri Lanka Sudan Suriname Swaziland Sweden Switzerland Syria Taiwan Tajikistan Tanzania Thailand Timor Leste Togo Trinidad & Tobago Tunisia Turkey Turkmenistan Turks & Caicos Islands Uganda Ukraine United Arab Emirates Uruguay Uzbekistan Venezuela Vietnam Virgin Islands (UK) Virgin Islands (US) Yemen Zambia Zimbabwe
Province of Origin Newfoundland Nova Scotia New Brunswick Prince Edward Island Quebec Ontario Manitoba Saskatchewan Alberta British Columbia Yukon Northwest Territories Nunavut
Visiting Country/State Canada United States of America Mexico France Cuba Dominican Republic Italy Germany China Spain Netherlands Republic of Ireland Hong Kong Bahamas Australia Afghanistan Albania Algeria Andorra Angola Anguilla Antigua & Barbuda Argentina Armenia Australia Austria Azerbaijan Bahamas Bahrain Bangladesh Barbados Belarus Belgium Belize Benin Bermuda Bhutan Bolivia Bosnia & Herzegovina Botswana Brazil Brunei Darussalam Bulgaria Burkina Faso Myanmar/Burma Burundi Cambodia Cameroon Cape Verde Cayman Islands Central African Republic Chad Chile China Colombia Comoros Congo Costa Rica Croatia Cuba Cyprus Czech Republic Democratic Republic of the Congo Denmark Djibouti Dominica Dominican Republic Ecuador Egypt El Salvador Equatorial Guinea Eritrea Estonia Ethiopia Fiji Finland France French Guiana Gabon Gambia Georgia Germany Ghana Great Britain Greece Grenada Guadeloupe Guatemala Guinea Guinea-Bissau Guyana Haiti Honduras Hong Kong Hungary Iceland India Indonesia Iran Iraq Israel and the Occupied Territories Italy Ivory Coast (Cote d'Ivoire) Jamaica Japan Jordan Kazakhstan Kenya Kosovo Kuwait Kyrgyz Republic (Kyrgyzstan) Laos Latvia Lebanon Lesotho Liberia Libya Liechtenstein Lithuania Luxembourg Republic of Macedonia Macau Madagascar Malawi Malaysia Maldives Mali Malta Martinique Mauritania Mauritius Mayotte Moldova Monaco Mongolia Montenegro Montserrat Morocco Mozambique Namibia Nepal Netherlands New Zealand Nicaragua Niger Nigeria North Korea Norway Oman Pacific Islands Pakistan Panama Papua New Guinea Paraguay Peru Philippines Poland Portugal Puerto Rico Qatar Reunion Romania Russian Federation Rwanda Saint Kitts and Nevis Saint Lucia Saint Vincent's & Grenadines Samoa Sao Tome and Principe Saudi Arabia Senegal Serbia Seychelles Sierra Leone Singapore Slovakia Slovenia Solomon Islands Somalia South Africa South Korea South Sudan Spain Sri Lanka Sudan Suriname Swaziland Sweden Switzerland Syria Taiwan Tajikistan Tanzania Thailand Timor Leste Togo Trinidad & Tobago Tunisia Turkey Turkmenistan Turks & Caicos Islands Uganda Ukraine United Arab Emirates Uruguay Uzbekistan Venezuela Vietnam Virgin Islands (UK) Virgin Islands (US) Yemen Zambia Zimbabwe
Visiting Province Ontario British Columbia Outside Canada
Do You Have Valid Provincial Government Health Insurance Coverage? No Yes
Which Province is Providing the Coverage? Ontario Quebec British Columbia Alberta Saskatchewan Manitoba Nova Scotia New Brunswick Prince Edward Island Newfoundland Yukon Northwest Territories Nunavut
Do You Require On-Going Coverage for More Than One Year? No Yes
Number of Applicants 1 2 3 4 5 6 7 8 9 10+
Name, Gender and Date of Birth of All Applicants
Do You Know Your Required Coverage Start And End Date? Yes No
Number of Days for Which You Require Coverage
Question / Comments