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21st Century Travel Insurance Ltd.
Medicare International Travel Insurance for Canadians
(underwritten by Manulife Financial)
Who can apply:
TO BE ELIGIBLE FOR INSURANCE UNDER THIS POLICY, you must be at least 30 days of age and a resident of Canada covered by the Government Health Insurance Plan in your province of residence for the entire trip length.
Eligibility and Medical Questionnaire
Applicant : Name Age Province of residence Please choose Alberta British Columbia Manitoba New Brunswick Newfoundland and Labrador Nova Scotia Ontario Prince Edward Island Saskatchewan
Single-Trip Medical Plan Annual Multi-Trip Medical Plan* Total Number of days per trip
* For Annual Multi-trip plans, you can chose 4, 10, 18, 30 and 60 days per trip
** If you are topping-up your existing policy, please provide the details in section Notes below
Section 1 - Eligibility
Please answer the following medical questions to determine your eligibility.
On the date you apply for this coverage and on the effective date:
1
Have you been advised by a physician not to travel at this time?
Yes No
2
Do you have a terminal illness for which a physician has estimated you have less than six (6) months to live?
3
Do you have metastatic cancer (a cancer that has spread from the original site to one or more other areas of the body)?
4
Do you require kidney dialysis?
5
Have you been prescribed or used home oxygen in the last twelve (12) months?
6
Have you had a bone marrow, stem cell or organ transplant (excluding corneal transplant) ?
If you must answer YES to any of the medical questions in Section 1, you are not eligible to purchase this policy.
Please continue to Section 2, if you have to answer NO to all questions in Section 1.
Section 2 - Declaration
I am eligible to apply for this policy. I declare that all the information I am providing on this application is true and complete. I understand the meaning of treatment/treated, as defined and used in this questionnaire.
I understand that this coverage is subject to terms, conditions, limitations and exclusions (including the pre-existing condition exclusion); and, that this coverage may exclude or limit an amount payable if I have a claim.
I understand that if I misrepresent any material information provided in this application, Manulife will void my policy and I will not be covered for any benefits under this policy.
I authorize any hospital, physician, other medical service provider or any other organization or person that has any records or knowledge of me or my health to release to the assistance and claims service provider and/or Manulife and its reinsurers any such information for the purpose of this application and contract and any subsequent claim.
Please confirm : Yes No
Applicants 60 year of age or older must answer the following questions to determine eligibility and rate category.
IF YOU ARE UNCERTAIN OF YOUR ANSWERS TO ANY OF THE MEDICAL QUESTIONS, PLEASE CONSULT YOUR DOCTOR BEFORE COMPLETING THIS APPLICATION FOR TRAVEL INSURANCE
Section 3 - Do you require Individual Medical Underwriting?
In the last four (4) months, have you been prescribed or taken six (7) or more prescription medications?
Do not count the following medications: hormone replacement therapy (thyroid or menopausal); drugs used for osteoporosis, or travellers diarrhea; or any form of immunization.
Do not count topical medications that go in your nose, ears or eyes or on your scalp or skin except any form of nitroglycerine or any drug(s) for angina.
In the last three (3) years, have you been diagnosed with, taken or been prescribed medication, or been treated for any two (2) of the following? (if you only have one (1) of the following conditions, answer NO)
Heart condition; Lung condition (except unrepeated prescription medications used for a single episode) (medication includes any puffer(s)/inhaler(s)); Stroke/CVA (cerebrovascular accident) or mini-stroke/TIA (transient ischemic attack) (including use of aspirin/Entrophen for this condition); Diabetes (treated with medication and/or insulin); Narrowed or blocked artery in the legs (also called Peripheral Vascular Disease)
In the last two (2)years, have you been:
a) diagnosed with, taken or been prescribed medication, or been treated for heart failure or congestive heart failure, and/or
b) prescribed or taken Lasix or Furosemide or a water pill for heart failure, ankle or leg swelling, or water on the lungs?
In the last twelve (12) months, have you had:
a) a new heart condition, or had an existing heart condition for which you had a change in medication or were hospitalized (as an in-patient or seen in the emergency department); and/or
b) investigative testing or treatment for shortness of breath or chest pain; and/or
c) a lung condition for which you were hospitalized (as an in-patient or in the emergency department)or for witch you have been prescribed or taken Prednisone; and/or
d) cancer or received chemotherapy and/or radiotherapy and or other treatment, other than routine follow-up, for cancer (except basal cell and squamous cell skin cancer, and breast cancer treated only with hormonal therapy)?
Have you had a heart bypass, angioplasty or heart valve surgery more than ten (10) years ago?
Section 4 - Smoker Status
In the last two (2) years, have you smoked cigarettes, and/or used vaping products or e-cigarettes?
Section 5 - Rate Category Qualification
Have you EVER been diagnosed with or treated for:
a) Heart condition
b) Aortic aneurysm (including thoracic or abdominal aneurysm)
c) Cirrhosis of the liver
d) Parkinson's disease
In the last three (3) months, have you been prescribed or taken a total of three (3) or more medications for high blood pressure (hypertension) ?
In the last five (5) years, have you been diagnosed with, taken or been prescribed medication for, or been treated for any of the following?
a) Lung condition (except unrepeated prescription medications used for single episode) (medication includes any puffer(s)/inhaler(s));
b) Stroke/CVA (cerebrovascular accident) or mini-stroke/TIA (transient ischemic attack)(including use of aspirin/Entrophen for this condition);
c) Diabetes (if treated with medication and/or insulin);
d) Narrowed or blocked artery in the legs or in the neck.
Section 6 - Rate Category Qualification
In the last two (2) years, have you been diagnosed with, taken or been prescribed medication, or treated for any of the following conditions?
1a
Bowel obstruction OR have had bowel surgery;
1b
Gastrointestinal bleeding;
1c
Chronic bowel disorder (such as but not limited to Crohn's disease or Ulcerative colitis);
1d
Liver disorder;
1e
Pancreatitis;
1f
Kidney disorder (including stones);
1g
Gallbladder disorder (including stones. Not applicable if gallbladder has been removed.)
Section 7 - Rate Category Qualification
In the last two (2) years, have you been diagnosed with and/or been treated by a Hematologist or an Internist for a blood disorder?
Are you over 70, and have you had a fall for which you sought medical attention in the last six (6) months?
In the last six (6) months, have you received advice or treatment for a medical emergency more than twice in the emergency room of a hospital?
Yes N
Notes
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Please confirm you are not a Robot or AI:
Your E-mail
Definitions
Treatment, Treated means hospitalization, prescribed medications (including medication prescribed "as needed"), medical, therapeutic, diagnostic or surgical procedure prescribed, performed or recommended by a licensed medical practitioner. IMPORTANT: Any reference to testing, tests, test results, or investigation excludes genetic tests."Genetic test" means a test that analyzes DNA, RNA or chromosomes for purposed such as the prediction of disease or vertical transmission risks, or monitoring, diagnosis prognosis