travel insurance application

Important reason to disclose all medical history. Read More

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APPLICANTS INFORMATION

First Name *

Last Name *

Date of Birth:

Month

Day *

Year *

Age *

Gender *MaleFemale

Age:

PRIMARY RESIDENCE

Street Address *

City *

Province *

Postal Code *

Phone *

E-mail Address

Travel - Medical Questions Required for Travel Coverage (Applicant)

The following medical questions are required for all travelers covered on this travel policy aged 70+.

Pre-existing conditions are based on Age of the Traveler(s)

Pre-existing conditions could affect your coverage if the answer to any of the medical questions are 'YES', up to the date of departure for your trip(s).

If the answer to any of the medical questions are 'YES' than a conversation with Arlene Marko, of our Travel Team is required.

1) Have you received medical advice, consultations, or treatment within 6 months (age 70-80) prior to the date of departure of a trip out of your home province? *YesNo

Details:

2) Have you received a prescription or a change (up or down) to an existing prescription within 6 months (age 70-80) of the date of departure of a trip out of your home province? *YesNo

Details:

3) Do you have a diagnosis for a chronic condition for a disease or disorder which has existed for a minimum of 6 months (age 70-80) prior to the date of departure of a trip out of your home province? *YesNo

Details:

4) Have you ever been treated for any form of heart condition or stroke for a minimum of 6 months (age 70-80) prior to the date of departure of a trip out of your home province? *YesNo

5) Has your doctor given any indication of any risk because of your health not to travel 6 months (age 70-80) prior to date of departure of a trip? *YesNo

Details:

Date of last correspondence with doctor? *Phone call, Virtual meeting, In person

Exclusions and Limitations

** any condition for which the Insured Person received medical advice, consultation or treatment within six (6) months prior to the commencement of a Trip, with the exception of a Chronic Condition which is under treatment and Stabilized by the regular use of prescribed medication.

"Chronic Condition" means a disease or disorder which has existed for a minimum of six (6) months.

"Stabilized" means there has not been a change in the medical condition requiring medical or psychiatric intervention for a minimum of six (6) months, adjustments in doses of Warfarin or Coumadin are not considered to be medical intervention for the purpose of this definition.

SPOUSE INFORMATION

Do You Have A Spouse? *YesNo

First Name *

Last Name *

Date of Birth:

Month

Day *

Year *

Age *

Gender *MaleFemale

Age:

Travel - Medical Questions Required for Travel Coverage (Spouse)

The following medical questions are required for all travelers covered on this travel policy aged 70+.

Pre-existing conditions are based on Age of the Traveler(s)

Pre-existing conditions could affect your coverage if the answer to any of the medical questions are 'YES', up to the date of departure for your trip(s).

If the answer to any of the medical questions are 'YES' than a conversation with Arlene Marko, of our Travel Team is required.

1) Have you received medical advice, consultations, or treatment within 6 months (age 70-80) prior to the date of departure of a trip out of your home province? *YesNo

Details:

2) Have you received a prescription or a change (up or down) to an existing prescription within 6 months (age 70-80) of the date of departure of a trip out of your home province? *YesNo

Details:

4) Have you ever been treated for any form of heart condition or stroke for a minimum of 6 months (age 70-80) prior to the date of departure of a trip out of your home province? *YesNo

5) Has your doctor given any indication of any risk because of your health not to travel 6 months (age 70-80) prior to date of departure of a trip? *YesNo

Details:

Date of last correspondence with doctor? *Phone call, Virtual meeting, In person

Exclusions and Limitations

"Chronic Condition" means a disease or disorder which has existed for a minimum of six (6) months.

travel insurance application

Please allow application time to load or refresh the page.

Please follow the instructions carefully in each section.

allow us the opportunity to provide you with a second opinion on your travel insurance

for information and ideas

travel insurance application

Please allow application time to load or refresh the page.

Please follow the instructions carefully in each section.

BEGIN APPLICATION HERE

DATE OF TRAVEL

allow us the opportunity to provide you with a second opinion on your travel insurance

for information and ideas