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Travel Insurance Subscription Form
(including International student insurance)

English name

gender

Birth date

Effective Date

Expiry Date

E-mail

연락처

Address (leave blank if you do not have a Canadian address)

Pre-existing medical condition means any health condition, disease (diabetes, high blood pressure, thyroid, etc.) or injury for which you have had a previous medical history and have been consulted, diagnosed and treated by a doctor.

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Name

Number

신용카드 유효일 (YYYY/MM)

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