Manulife Financial
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:

Trip Information

Section 1 - Declaration

I declare that all the information I am providing on this application is true and complete. I understand that "treatment" and "treated" as used in the questionnaire means hospitalization, a procedure prescribed, performed, or recommended by a physician for a medical condition. This includes but is not limited to prescribed medication, investigative testing, and surgery.
IMPORTANT: Any reference to testing, tests, test results, or investigations excludes genetic tests. “Genetic test” means a test that analyzes DNA, RNA or chromosomes for purposes such as the prediction of disease or vertical transmission risks, or monitoring, diagnosis or prognosis. 
I understand that this coverage is subject to terms, conditions, limitations, and exclusions, including any applicable pre-existing condition exclusions, and this policy 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, medical service provider, any organization, or person that holds my records or has knowledge of me and my health to release this information to the Assistance Centre and/or Manulife and its reinsurers for the purpose of this application, contract, and any subsequent claims.
All information I provide in this application is true and complete

Section 2 - Eligibility

Eligibility questions:
Have you been advised by a physician not to travel at this time?
Do you have a terminal illness for which a physician has estimated you have less than six (6) months to live?
Do you require kidney dialysis?
Have you been used home oxygen in the last twelve (12) months?
Do you reside in Canada on the application date?
Will you be covered under a government health insurance plan (GHIP) for the entire duration of your trip?

Section 3 - Do you require Individual Medical Underwriting?

Have you had a heart bypass, coronary angioplasty or heart valve surgery more than ten (10) years ago?
In the last three (3) years, have you been diagnosed with, taken or been prescribed medication, or been treated for the following conditions:
Heart condition;
Lung condition, except unrepeated prescription medications used for a single episode (medication includes any puffers/inhalers);
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:
Been diagnosed with, taken or been prescribed medication, or been treated for heart failure or congestive heart failure?
Been prescribed or taken Lasix or furosemide or a water pill for ankle or leg swelling or water on the lungs?
In the last twelve (12) months, have you had:
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);
Shortness of breath or chest pain for which you sought treatment;
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)?
A lung condition for which you were hospitalized (as an inpatient or seen in the emergency department) or for which you have been prescribed or taken prednisone?
In the last four (4) months, have you been prescribed or taken six (6) or more prescription medications?
Do not count the following medications: hormone replacement therapy (thyroid or menopausal); drugs used for osteoporosis, or traveller’s 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.

Section 4 - Smoking 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:
Heart condition
Aortic aneurysm (including thoracic or abdominal aneurysm)
Cirrhosis of the liver
Parkinson's disease
Alzheimer's disease or other form of dementia
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?
Lung condition (except unrepeated prescription medications used for single episode) (medication includes any puffer(s)/inhaler(s));
Stroke/CVA (cerebrovascular accident) or mini-stroke/TIA (transient ischemic attack)(medication includes use of aspirin/Entrophen for this condition);
Diabetes (if treated with medication and/or insulin);
Narrowed or blocked artery in the legs OR in the neck.
In the last two (2) years, have you been diagnosed with, taken or been prescribed medication for, or been treated for any of the following conditions?
Bowel obstruction OR have had bowel surgery;
Gastrointestinal bleeding;
Chronic bowel disorder (such as but not limited to Crohn's disease or Ulcerative colitis);
Liver disorder;
Pancreatitis;
Kidney disorder (including stones);
Gallbladder disorder (including stones).
Not applicable if gallbladder has been removed.
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 age 71 or older and in the last six (6) months, have you had a fall for which you sought medical attention?
In the last six (6) months, have you received advice or treatment in the emergency room of a hospital 3 or more times?

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