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TuGo TRAVELLER
Travel Insurance Medical Questionnaire

Applicants 60 + years of age must answer the following questions to determine insurance rate.

If you have any doubt about your medical condition (s) as it relates to the following questions, you should consult your physician for advice before completing this medical health questionnaire.

You are eligible for coverage if:

Yes

No

You are a Canadian resident  covered by a provincial health insurance plan for the entire trip length;
You are not traveling against a physician's advice;
You have not been diagnosed with a terminal condition.
You are not receiving palliative care or palliative care has not been recommended.

 I confirm that I understand and meet eligibility requirements above:

Choose the one most recent event:

Less than 1 year ago

1 to 5 years ago

More than 5 years ago

1 to 5 years ago

More than 5 years ago

Choose the one most recent event:

a). Have you experienced myocardial infarction also known as heart attack, stroke or Transient Ischemic Attack (TIA) also known as mini-stroke?

Choose a condition if, in the specified timeframe, you had the condition, whether or not you received any medical care for it.

This includes conditions controlled or managed by medication, a medical device, diet or exercise.

b). Have you experienced Arterial by-pass, angioplasty and/or the placement of a stent for a cardiovascular condition?

None

None

Less than 1 year ago

Pancreatic cancer

Yes with an alteration to your medication in the last 6 months

None

None

Liver cancer

Any type of cancer that has metastasized or that required a bone marrow transplant, excluding pancreatic or liver cancer

Have you had any of these CANCER conditions in the last 12 months?

Do you currently have hypertension also known as high blood pressure?

Have you had any of these conditions in the last 12 months?

Osteoporosis

Hyperthyroidism

Kidney stones

Kidney disease not requiring dialysis

Dementia including Alzheimer’s  disease

Pancreatitis

Liver disease, excluding liver cancer

Gallbladder disease, including gallstones

Parkinson’s Disease (PD)

None

Hypothyroidism

Kidney disease requiring dialysis

Diabetes requiring insulin

Asthma requiring prednisone

Pneumonia

Two or more bronchitis episodes

None

b). Have you had any of these GASTROINTESTINAL conditions in the last 12 months?

Peptic ulcer, either stomach or duodenal

None

a). Have you had any of these RESPIRATORY conditions in the last 12 months?

Asthma not requiring prednisone

Chronic Obstructive Pulmonary Disease (COPD), including emphysema, not requiring home oxygen

Chronic Obstructive Pulmonary Disease (COPD), including emphysema, requiring home oxygen

Angina

Peripheral Vascular Disease (PVD)

Aortic aneurysm that is 4cm or larger

Congestive heart failure also known as pulmonary edema

Arteriosclerosis and/or atherosclerosis also known as hardening of the arteries

Have you had any of these CARDIOVASCULAR conditions in the last 12 months?

Yes

No

In the last 12 months, have you smoked any tobacco products, or vaped any nicotine products (including e-cigarettes)?

None

High cholesterol

Deep Vein Thrombosis (DVT)

Single Trip:

Province of residence:

Travel destination:

Age:

Name:

Multi-Trip:

Days per Trip:

Days per each Trip:

Please enter your E-mail:

Multi-Trip+Top-Up

Top-Up:

Total Trip Duration:

Days per each Trip:

Your longest trip duration:

Number of days under existing policy:

If you’ve been diagnosed with any type of arthritis such as osteoarthritis, rheumatoid arthritis or psoriatic arthritis, choose this condition.

If you’ve been diagnosed with diabetes that’s treated either by lifestyle changes such as diet, exercise or with any kind of medication other than insulin, choose this condition.

      Don’t choose this condition if you’ve been diagnosed with Impaired Glucose Intolerance (IGT), also known as pre-diabetes.

A bladder infection is a specific type of Urinary Tract Infection (UTI). Choose this condition if you’ve had two or more bladder infections, and not any other types of UTIs.

Alteration: the medication usage, dosage or type has been increased, decreased or stopped and/or a new medication

has been prescribed.

Alteration does not include:

a) Changes in brand due solely to the availability of your usual brand or due to a change from a brand name medication to

an equivalent generic brand medication of the same usage or dosage; and

b) The routine adjustment of the dosage within prescribed parameters to ensure correct blood levels are maintained when

you are taking insulin or oral diabetes medication or blood thinner medication such as Coumadin/Warfarin and your

blood levels must be checked regularly and your condition remains unchanged; and

c) The usage changes due to the combination of several medications into one and your condition remains unchanged

Remission: the decrease in or the disappearance of signs and symptoms of cancer and/or the removal of cancer as determined by your physician and noted in your medical records.

   Remission can be complete or partial. Complete remission means the disappearance of all signs or symptoms.

   Partial remission means a decrease in or disappearance of some, but not all, signs and symptoms

If you’ve only been diagnosed with diverticulosis, don’t choose this condition.

However, if you’ve been diagnosed with diverticulitis and diverticulosis, choose this condition.

If you’ve been diagnosed with Gastroesophageal Reflux Disease that’s treated with prescribed medication such as proton pump inhibitors to stop the production of acid in the stomach, choose this condition.

 

Don’t choose this condition if you have occasional heartburn or acid reflux that hasn’t been diagnosed as GERD, even if you’re taking over-the-counter medication for it such as TUMS® or Rolaids®.

Coronary Artery Disease can be caused by arteriosclerosis and/or atherosclerosis.

If you’ve been diagnosed with CAD and arteriosclerosis and/or atherosclerosis, choose all these conditions.

Atrial fibrillation is a type of arrhythmia.  Choose this condition if you’ve been diagnosed specifically with atrial fibrillation and not any other type of arrhythmia or

dysrhythmia.

Choose Single Trip plan if you’d like insurance for one trip from your province of residence or Canada. (Coverage commences upon your departure from your province of residence and expires when you return to your province of residence, no matter how many countries you visit during the trip).

Choose Annual Multi-trip plan if you’d like insurance for many trips taken in the next 12 months (Coverage for each separate trip commences immediately upon your departure from your province of residence and expires when you return to your province of residence. Each trip cannot exceed the maximum days you selected when you purchased your Multi-Trip plan).

Choose Top-Up if your trip is longer than the number of days covered under your existing policy (Coverage starts on the date after the date when your existing coverage expires).

Choose Annual Multi-trip +Top-Up if you’d like insurance for many trips during 12 months and a Top-Up for one trip which is longer than the number of day per trip allowed under the multi-trip plan.

A weight-to-height ratio measured by Body Mass Index (BMI) greater than 40. Severe obesity must be diagnosed by a

physician or other registered medical practitioner and be recorded in your medical records.