Temporary Insurance

To whom it may concern

I _____________________________ authorize David Duquet of DD service d’accueil et

name

d’intégration, to buy temporary insurance for me, before my arrival to Canada.

Answer by yes or no

1. Has your doctor advised you not to travel? __________

2. Do you suffer from a terminal illness? __________

3. Do you suffer from kidney failure treated through dialysis? _________

4. In your life, have you ever been diagnosed with or treated for metastatic cancer? _______

5. In the past 12 months, have you been diagnosed with, had treatments or taken medication for

cancer (with the exception of basal cell carcinoma)?_______________

6. Do you suffer from heart failure or cardiomyopathy? _____________

7. Are you waiting for an organ transplant for one or several of the following: Kidneys, lungs,

liver, heart, bone marrow, pancreas? ___________

8. In the past 24 months, have you used home oxygen or taken cortisone pills for a pulmonary

condition? _______________

____________________________ ________/_________/_______
worker signature Date D M Y

SIN​ (temporary social insurance number)

question that you have to prepare to have your temporary SIN:
given name family name at birth
1. - Mother’s name at birth _________________/__________________
2. - Father’s name at birth _________________/__________________