True Senior Guard Travel Insurance Plan

Eligibility and Medical Questionnaire

(applicants 60 + years of age must answer the following questions to determine insurance rate)

Applicant Information

Name of Applicant:
Age of Applicant:
Name of Co-Applicant:
Age of Co-Applicant:

Trip Information

Eligibility

You must meet the following eligibility requirements on the departure date of each trip in order to be eligible for coverage.
You are eligible for coverage if:
a) You are a Canadian resident  covered by a provincial health insurance plan for the entire trip length,
b) You are not traveling against a physician's advice, or
c) You know of no reason to seek consultation during the trip, or
d) You have not been diagnosed with a terminal condition with a life expectancy of 6 months or less.

I confirm that I understand and meet the eligibility requirements above
You are not eligible for True senior Guard Plan. To select the insurance plan best suited to your insurance needs, please complete online our General Medical questionnaire.

Rate Classification Questions

At the time of application, how many medications in total do you take or been ordered to take by a physician to treat one or more of the following conditions:
A heart condition?
(Do not include aspirin, high blood pressure
* and cholesterol medication *)  
A lung/respiratory condition
(EXCLUDING Astma and/or seasonal allergies, INCLUDING inhalers, puffers, and home oxygen)
Diabetes
(treated with oral medications or insulin)
Stroke and/or transient ischemic attack (mini-stroke, TIA)
(Do not include aspirin)
(*) - You do not have to count high blood pressure and cholesterol medications in this question, if these medications were prescribed ONLY to treat high blood pressure and/or cholesterol conditions. If these medications are given to treat the heart, you should count them in this question.
At the time of application, are you being treated, taking or have been prescribed medication for any of the following (including Aspirin or Entrophen):
AIDS or HIV
Bowel obstruction or bowel surgery
Cancer (excluding basal cell/squamous cell skin cancer)
Cholesterol
Crohn's disease
Dementia and/or Alzheimer's
Diabetes (treated with oral medications or insulin)
Fibromyalgia
Gastrointestinal bleeding
High Blood Pressure (HBP)
Heart condition(s)/disease (INCLUDING aspirin)
Kidney disease (INCLUDING kidney stones & dialysis)
Liver disease
Lung condition(s)/disease (INCLUDING asthma and/or seasonal allergies)
Pancreatic disease
Parkinson's disease
Seizures
Spleen disease
Stroke (CVA) and/or mini-stroke (TIA) (INCLUDING aspirin)
Ulcerative colitis
Has it been longer than 12 months since you last seen a doctor or nurse practitioner?
Have you used any tobacco or nicotine products in the past 24 months?
Coverage for pre-existing medical conditions
You can choose the stability period for coverage for pre-existing medical conditions. If you experience a change to your health or treatment within a stability period before your departure date, this condition will not be covered.
Stability period for pre-existing conditions (age 60 and over)
Stability period for pre-existing conditions (age 59 and less)
Stability period for pre-existing conditions (age 60 and over)
Stability period for pre-existing conditions (age 59 and less)

Submit your Questionnaire

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