HMC Travel Insurance Plan

( underwritten by Empire Life insurance company )

Eligibility and Medical Questionnaire

Applicant Information

Name of Applicant:
Age of Applicant:

Trip Information

Do you require coverage in the USA or Mexico (e.g. transit stop)?

Eligibility

To be eligible for coverage under the contract, as of the Application Date, a Person Insured must be physically present in Canada. This requirement does not apply if You are applying for a Single Trip Coverage as a Top-Up.
To be eligible for coverage under the contract, as of the Effective Date, a Person Insured must:
1) be a Canadian citizen or permanent resident or be a visitors toCanada;
2) be at least 15 days old and less than 95 years of age;
3) be the Policyowner, unless the sole Person Insured is under the age of 18 (if in Quebec) or age 16 (all other Canadian provinces or territories), in which case the Policyowner must be the Person Insured’s parent or legal guardian;
4) if not the Policyowner, be a Spouse or Dependent of the Policyowner; and
5) be insurable in accordance with Our then-current underwriting rules.
A Person Insured is not eligible for coverage under the contract if, as of the Effective Date, any of the following applies to a Person Insured, even if disclosed on the Application:
• They are experiencing new or undiagnosed signs or symptoms of a Sickness for which they reasonably expect may require Treatment while the contract is in force, or otherwise have a reasonably foreseeable need for Treatment while the contract is in force;
• In the 12 months prior to the Effective Date, they have:
a) Received a diagnosis of Stage 3 or Stage 4 cancer, had cancer that has metastasized or received Treatment for pancreatic cancer or liver cancer;
b) Received a Terminal Prognosis or Amyotrophic Lateral Sclerosis (ALS, Lou Gehrig's disease);
c) Been prescribed home oxygen (including an oxygen concentrator) or prednisone for a Lung Condition or Heart Condition;
d) Had Pulmonary Fibrosis, Cystic Fibrosis, or Interstitial lung disease;
e) Been diagnosed with or received Treatment for Stage IV or Stage V Kidney disease, kidney disease requiring dialysis, or Cirrhosis of the liver;
f) Used nitroglycerine in any form (spray, patch, or pill) for a Heart Condition for the relief of angina or chest pain or had Cardiomyopathy with a Grade IV ventricle or a ventricular ejection fraction of 40% or less;
g) Had a dilation of the aorta or an aneurysm that has not been surgically repaired;
h) Been a resident in a long-term care facility or an assisted living facility where You were helped with any activities of daily living (bathing, eating, using a toilet, taking Medication(s) or getting into or out of a chair or bed);
i) Been advised by any Physician that traveling on Your trip would be medically unsafe or that You should not travel on Your trip;
• In the 3 years prior to the Effective Date, they have received Treatment for aplastic anemia, hemolytic anemia, sickle cell anemia, or anemia requiring blood transfusions or bone marrow transplants, or have received Treatment in a Hospital for anemia through iron supplements;
• They have received Treatment for or taken Medication for Congestive Heart Failure (CHF) in the past 5 years; or
• They have undergone a bone marrow transplant, stem cell transplant or an organ transplant (except for a cornea transplant);
I confirm that I understand and meet the eligibility requirements above
If you are not eligible for the True Senior Guard Plan, please complete our General Medical Questionnaire online to help us determine the insurance plan best suited to your needs.

Rate Classification Questions

Answers on the questions:
Each question below requires the applicant to answer either "Yes" or "No" depending on whether the applicant has had such a condition, including symptoms or investigation or consultation concerning a certain condition.
If the applicant answers "Yes" to any condition, the applicant must state how many medications they are taking for that condition and for how long the condition has been stable.
CIRCULATORY, VASCULAR OR BLOOD DISORDERS:
In the last 5 years have you had, have been diagnosed with, treated for or been prescribed or taken medication for :
High Blood Pressure (Hypertension), Low Blood Pressure (Hypotension) or Edema (Oedema).
Peripheral Vascular Disease (PVD), peripheral artery disease (PAD) or repaired aneurysm (excluding varicose veins and venous stasis).
Carotid stenosis of 50% or more not repaired by surgery.
Anemia other than Aplastic anemia, Hemolytic anemia, Sickle cell anemia or anemia requiring blood transfusions or bone marrow transplants in the past 3 years.
HEART OR CARDIOVASCULAR:
Have you ever been diagnosed with, treated for or been prescribed or taken medication for :
Disorders of the heart rhythm or conduction including atrial fibrillation, arrhythmia and bundle branch block or a pacemaker implant.
Heart attack (Myocardial infarction), Arteriosclerosis, Chest pain, Angina, or Coronary artery disease (CAD)
(answer NO if a bypass, angioplasty or stent was inserted after your last heart attack).
Surgery for Heart by-pass, Angioplasty or Stent less than 16 years ago.
Surgery for Heart by-pass, Angioplasty or Stent 16 or more years ago.
Valvular heart disorder or last surgery less than 8 years ago.
Valvular heart surgery or an implanted cardioverter-defibrillator (ICD) 8 or more years ago.
Any other heart/cardiovascular conditions not listed above (describe in a note).
STROKE, CEREBROVASCULAR OR NEUROLOGICAL:
Have you ever been diagnosed with, treated for or been prescribed or taken medication for :
Stroke, Cerebrovascular accident (CVA), Mini Stroke, Transient ischemic attack (TIA).
Syncope or dizzy spells or fainting that was reported to a doctor or hospital.
Dementia or Alzheimer's disease.
Parkinson's disease, epilepsy, muscular dystrophy, cerebral palsy, multiple sclerosis, myasthenia gravis or other neurological conditions.
RESPIRATORY OR LUNG:
In the last 3 years have you had, have been diagnosed with, treated for or been prescribed or taken medication for :
Chronic Obstructive Pulmonary Disease (COPD), chronic bronchitis, emphysema or asbestosis.
Other chronic respiratory condition, lung disorder, lung surgery or a removal of any portion of the lung. (This does not include asthma, seasonal allergies or a minor ailment).
KIDNEY, GASTRO-INTESTINAL, DIGESTIVE OR LIVER:
In the last 3 years have you had, have been diagnosed with, treated for or been prescribed or taken medication for :
Bowel condition including ulcerative colitis, Crohn's disease, diverticulitis, bowel obstruction,bowel surgery, chronic constipation, Irritable Bowel Syndrome (IBS) or gastrointestinal bleed.
Hepatitis C.
Kidney disorder, pancreatitis, kidney stones not eliminated, gall stones not eliminated (ignore gall stones if the gall bladder was removed), 2 or more bladder or urinary tract infections in the last 12 months.
DIABETES:
In the last 3 years have you had, have been diagnosed with, treated for or been prescribed or taken medication for :
Diabetes — insulin only prescribed.
Diabetes — medication prescribed, insulin not required.
Diabetes - prescribed both insulin and oral medication.
CANCER:
Have you ever been diagnosed with, treated for or been prescribed or taken medication for :
Leukemia or Lymphoma or Multiple Myeloma (cannot be covered).
Have you had any other form of Cancer not including breast cancer treated with hormone therapy only and not including basal cell or squamous cell skin cancer.
In the 6 months prior to the effective date have you had surgery, chemotherapy or radiation therapy for cancer or malignant tumour(s) (excluding basal cell or squamous cell skin cancer or breast cancer treated only with hormone therapy).
OTHER RISK FACTORS:
In the 24 months prior to the effective date have you smoked or used tobacco products.
In the 12 months prior to the effective date have been prescribed or taken Lasix or Furosemide for any reason.
In the 6 months prior to the effective date have you received advice/treatment in a hospital for any of the conditions mentioned above in sections 2 through 8, or have you received advice/treatment in a hospital two or more times for any other medical condition (answer NO if the treatment was removal of the gall bladder or removal of kidney stones).
In the 6 months prior to the effective date have you had two or more falls that were reported to a physician.

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