Your quotes will be emailed you within one business day.

1-877-443-0101
If you have questions, or need help to complete the form, please call at
416-493-0101, 1-877-443-010
or
  Ask Your Question Online!

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:

It’s important to answer the Medical Questionnaire correctly. If you qualify for the insurance but inaccurately answered any of the Rate Qualification questions, a $15,000 USD deductible applies to any incident claimed, and an additional premium may be required.

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?

In all questions: 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)

Province of residence:

Travel destination:

Age:

Name:

Days per Trip:

Days per each Trip:

Please enter your E-mail:

Choose Trip Plan

Do you need SINGLE Trip Medical Plan   or annual MULTI-Trip Medical Plan?

Total Trip Duration:

Multi-Trip: Days per 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 to an equivalent name brand or to an equivalent generic brand of the same or equivalent usage

or dosage; or,

b) Routine dosage adjustments within prescribed parameters for insulin or oral diabetes medication to ensure correct

blood levels are maintained; blood sugar levels must be checked regularly and the medical condition must remain

unchanged; or,

c) Routine dosage adjustments within prescribed parameters for blood thinner medication to ensure correct blood levels

are maintained; blood levels must be checked regularly and the medical condition must remain unchanged; or,

d) A temporary stoppage of blood thinner medication up to a maximum of 24 hours if the stoppage is required for a

surgery or a procedure; or,

e) Usage changes due to the combination of several medications into one; the medical condition must remain 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).

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

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

Your answers on the Medical Questionnaire will determine the premium (cost) of your insurance.

 

It’s important to answer the Medical Questionnaire correctly. If you qualify for the insurance but you inaccurately answer any of the Rate Qualification Questions, a $15,000 USD deductible applies to any incident claimed, in addition to any other deductible you may have selected.

At the time of a claim, if the answers are not complete or accurate, coverage won’t be provided until you correct your answers, and if applicable, you pay any additional premium that may be required

 

If you’re unsure how to answer the question, talk to your physician for advice before completing the Medical Questionnaire

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.