Allianz Global Assistance
Travel Insurance for Canadians

Eligibility and Medical Questionnaire

(applicants 65 + years of age must answer the medical questions to determine insurance rate)

Applicant Information

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

Trip Information

Eligibility

To be eligible for coverage, all of the following conditions must be met:
1. As of the effective date of your policy you must
a) be at least 15 days old, and
b) be a Canadian resident and be insured for benefits under a Canadian government health insurance plan during the entire Coverage Period, and
c) not have been advised against travel by a physician for a period of time which includes your trip, and
d) not be travelling or going on your trip to receive treatment or alternative therapy of any kind.
2. In the two (2) years prior to the effective date, you must not have been diagnosed with or received treatment for a terminal condition for which a physician gave you a prognosis of eventual death or for which palliative care was or is being received.
3. If you are age 65 or older on the effective date, to be eligible for coverage you must not require assistance with activities of daily living including but not limited to, eating, bathing, using the toilet, changing positions (including getting in and out of a bed or chair), or dressing, as the result of a medical condition or state of health.
You are not eligible for Allianz Travel insurance. To select the insurance plan best suited to your insurance needs, please complete online our General Medical questionnaire.

Rate Classification Questions

In the past 6 months have you been prescribed, refilled or taken prescription medication for:
Blood pressure?
Stroke/mini-stroke(TIA), or prevention of a blood clot?
A heart condition?
Heart Condition means any condition relating to the heart or cardiovascular system.
A digestive condition (including GERD / acid reflax )?
Digestive condition means any condition related to your esophagus, stomach and intestines.
A lung/respiratory condition (excluding allergies)?
Lung/respiratory Condition means any condition related to the lung or respiratory system.
Diabetes or pre-diabetes?
In the past 6 months have you been prescribed, refilled or taken prescription medication for any other condition (do not include birth control medication, low-dose aspirin, or antibiotics) ?
Have you been diagnosed with or had any cancer treatment in the past 6 months?
(This does not include basal or squamous cell skin cancer or breast cancer treated only with hormone therapy).
Have you used any tobacco or nicotine products in the past 6 months?
Do you have an unrepaired aneurysm 4 cm or greater, measured in either length or diameter, diagnosed at any time before the effective date?
Have you used or been prescribed nitroglycerin in the 90 days before the effective date?
Have you been diagnosed with, received treatment for, or had an episode of congestive heart failure in the two (2) years before the effective date?
Do you have any kidney condition that required dialysis in the 90 days before the effective date?
Have you used or been prescribed home oxygen or oral steroids (inhalers are not considered oral steroids) for a lung/respiratory condition in the 90 days before the effective date?
Have you had any cancer treatment (other than for basal or squamous cell skin cancer or breast cancer treated only with hormone therapy) in the 90 days before the effective date?
Have you had any bone marrow, stem cell, or organ transplant (excluding skin or cornea) received or recommended in the two (2) years before the effective date?

Submit your Questionnaire

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