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TravelStar® Travel Insurance

 

Eligibility and Medical Questionnaire

 

 Applicant :  Name      Age  

Single-Trip Medical Plan     Annual Multi-Trip Medical Plan     Total Number of days per trip   

 

Do you qualify?

Section 1 - Eligibility

This section must be completed with the purchase of all Emergency Medical Insurance, or Trip Cancellation & Interruption Insurance where the trip value is greater than $12,000

 

1

Are you awaiting further tests or treatment for heart disease or have you ever been diagnosed with congestive heart failure (CHF)?

 

 Yes No

2

Do you have both heart disease and insulin dependent diabetes and take prescription medication for both?

 

 Yes No

3

Do you use home oxygen for a heart and/or lung disease?

 

 Yes No

4

Do you take oral steroids for a lung condition?

 

 Yes No

5

Do any of the following apply to you:

a) you are under active treatment for cancer or have metastatic cancer; or
b) you have an aortic or intracranial aneurysm that remains surgically untreated; or
c) you have experienced undiagnosed episodes of syncope/fainting or falling?
 

 Yes No

6

Do you have an ICD (Implantable Cardioverter Defibrillator)?

 

 Yes  No

7

In the past twelve (12) months:


a) Have you suffered from, been diagnosed with, received new treatment for, or had a recurrence of, or complications relating to any of the following?

- stroke/TIA

- blood clots

- atrial flutter

- atrial/ventricular fibrillation

- peripheral vascular disease
- AIDS

- any terminal illness

- renal/liver failure

- gastrointestinal bleeding

 

b) Have you undergone the following procedures?
- renal dialysis  

- valve replacement   

- valve surgery   

- organ transplant

 

 Yes No

If you answered NO to ALL of the above questions AND have provincial health coverage in place, you are eligible to purchase this plan.
 

 

What rate category do you qualify for?

Please complete this Questionnaire, if you are 60 years of aqe or older and are purchasing Single Trip Daily Emergency Medical Insurance

 

Section 2 

Have you ever suffered from, been diagnosed with, received treatment for, or been prescribed medication for any of the following medical conditions or undergone any of the following medical procedures?

 

1

Heart/Cardiovascular Disease or Condition, Heart Attack, Angina, Irregular Heartbeat, Heart Surgery, Coronary Angioplasty, Stenting, Bypass, Valve Replacement or Valve Surgery

 

 Yes   No

2

 Stroke/TIA, Blood Clots, Aneurysm, Peripheral Vascular Disease, Carotid Stenosis

 

 Yes   No

3

Chronic Lung Disease {e.g. Chronic Obstructive Pulmonary Disease {COPD /Emphysema/Persistent Asthma)

 

 Yes   No

4

Bone Marrow or Organ Transplant

 

 Yes  No

5

 HIV

 

  Yes  No

 

 

Section 3

In the past two (2) years have you suffered from, been diagnosed with, received treatment for or been prescribed medication for any of the following medical conditions?

 

a

Cancer (Excluding Basal Cell Carcinoma)

 

 Yes   No

b

Diabetes

 

 Yes   No

c

Pancreatitis
 

 Yes   No

d

Chronic Kidney Disease, Liver Disease, Gastrointestinal Disorders—including but not limited to Ulcers, Gl Bleed, Bowel Obstruction, Hepatitis, Crohn's Disease, Colitis or Diverticular Disease

 

 Yes   No

e

Epilepsy or Seizures

 

 Yes   No

f

Hospitalized as a result of a fall

 

 Yes   No

g

M.S., Lou Gehrig's Disease, Parkinson's Disease, Dementia or Alzheimer's

 

 Yes   No

 

 

Section 4 - Rate classification

 

1

Has it been more than eighteen (18) months since your last check-up with a physician?

 

Yes          No

2

In the last two (2) years, have you smoked or used any tobacco products?

 

Yes          No

 

 

 

Notes

 

 

Your E-mail   

 

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         Revised: March 22, 2012.