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TRAVEL UNDERWRITERS 

FREEDOM Travel Insurance

 

Medical Questionnaire

Applicants 60 - 89 years must answer the following questions to determine rate.

If you have any doubt about your medical condition (s) as it relates to the following questions, you should consult your physician for advice before completing this medical health questionnaire.***

 

Applicant : Name      Age          Destination:   

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

 *For multi-trip plans, you can choose from 5,10,20, 35, and 60 day annual plans.

 

1. At the time of application, how many medications* in total do you take or have you been ordered to take by a physician for one or more of the following medical conditions:

• Heart conditions/disease (include aspirin, but exclude medication" taken for hypertension or high cholesterol)

• Lung conditions (including asthma)

• Diabetes

 

3 or more medications    

2 medications 

1 medication  

None  

 

2. Within the 24 months prior to the date of application, have you had a heart attack, stroke and/or transient ischemic attack (mini-stroke, TIA)? 

  

YES        

   NO    

 

 

3. At the time of application, how many of the following medical conditions are you receiving medical treatment for?

(Medical treatment includes medication* that you take or have been ordered to take by a physician)

  • Heart conditions/disease (include aspirin)

  • Lung conditions/disease (including asthma)

  • Diabetes (controlled by medication or diet)

  • Hypertension

  • Diverticulitis

  • Bowel obstruction

  • Peptic ulcer

  • GERD (gastro-esophageal reflux disease)

  • Kidney infections

  • Kidney stones

  • Kidney failure

  • Cancer

 

2 or more medical condition  

1 medical condition 

None 

 

4. Have you ever been diagnosed with ANY medical conditions that are not listed in the previous questions, for which you currently receive medical treatment?    

(Medical treatment includes medication* that you take or have been ordered to take by a physician, not including a minor ailment**.)

 

YES        

   NO    

 

5. Have you used any tobacco products in the past 12 months? 

 

YES       

   NO      

 

*Medication(s) includes medication that requires a prescription from a physician or other registered medical practitioner and medication purchased over the counter as per the physicians advice or other registered medical practitioners advice.

** Minor ailment means a condition which does not require the use of medication for a period of greater than 30 days, which did not require follow-up or referral visit to a physician, registered medical practitioner, or which did not require hospitalization or surgical intervention.

 *** If you qualify for the coverage selected but fail to answer truthfully and accurately any question asked at the time of the application, any claim will be subject to an extra deductible of $10,000 in addition to any other applicable deductible amount. No future coverage will be provided under this Policy unless you pay any additional premium reflecting true and accurate answers to those questions.

 

Notes

 

 

Your E-mail   

 

Revised: May 14, 2012