As the policyholder to the Plan, you are the legal representative towards Golden Care of all persons to insure included on this application form. The policyholder may choose not to be insured if cover is required for dependant(s) only.
C Persons to be insured
Fill out the section below, after reading the following specifications:
Area 1: Worldwide limited to 30 days per year in the United States and Canada
- Area 2: Worldwide
- If your child is between 21 and 24 years ol and full-time student, he/she benefits from the 0-20 years-old premium rate. Please attach proof of student status.
- Any child up to 20 years old applying alone will be charged the 21 to 24-year-old rate. If several children apply together, the oldest will be charged the adult rate.
Do you wish to insure another child?
Do you wish to insure another family member?
Please select the frequency of your premium:*