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CVIS Canadian Reg. Man.


A Single Application for All Travel Insurance Plans

STEP 1: TRAVEL AND TRIP INFORMATION

What is your birth date?   (yyyy-mm-dd)
Effective Date of this policy (yyyy-mm-dd)
Termination Date of this policy (yyyy-mm-dd)
OR Duration of coverage days
Add-ons (Optional):    
Top-up: extending your insurance coverage?To top-up or extend coverage of an annual plan, or to purchase coverage after the departure.
  1. Click Yes and enter the Departure Date (i.e., the date you left or intend to leave Canada,)
  2. Enter the Effective Date for the desired extension,
  3. Enter the Termination Date or the Duration of the coverage you wish to purchase.
Yes No
Departure date from Canada: Enter the date you left or intend to leave Canada; it must preceed the Effective date of this policy. (yyyy-mm-dd)
Coverage details:    

STEP 2: UNDERWRITING OPTION - choose one of the options from the following menu:

 
I declare that I do not want coverage for any pre-existing conditions.
I will complete the medical questionnaire.
TAKE A RISK
COVER MY CONDITION(S)

 

STEP 3: MEDICAL QUESTIONNAIRE - your answers form the medical statement and become part of the policy. The onus is on you to tell the insurer everything that has affected your health status.You must click Yes for any condition that you had symptoms, been investigated for, received consultation or Treatment for, or had a change in medication or a change in Treatment for, been Hospitalized for or been diagnosed with.
  1. Check whether the stability clause is based on the Effective Date or the Application Date.
  2. If you have been prescribed medicine or a course of care by a doctor or have sought care from a licensed practitioner, you will be considered to have received treatment for a medical condition or injury.
  3. Certain underwriting rules may exclude a condition or reject the application.
  4. The policy is void if there is a material mistake in the medical statement.

Medical Conditions

Current Medications

The medical condition has been Stable for

 
ELIGIBILITY:
If you answer Yes to one of the questions in this section you are not eligible for coverage under this policy.      
Have you been diagnosed with or received treatment for a Stage IV or Stage V Chronic Kidney Disease, kidney disease requiring dialysis or Cirrhosis of the Liver
Yes No
N/A  N/A   
In the 12 months prior to the effective date have you been advised by a physician not to travel
Yes No
N/A  N/A   
In the 12 months prior to the effective date have you been diagnosed with a terminal illness, Stage 3 or Stage 4 cancer, cancer that has metastasized, received treatment for pancreatic cancer, liver cancer, or have HIV, AIDS or AIDS-related complex
Yes No
N/A  N/A   
In the 12 months prior to the effective date have you taken or been prescribed home oxygen or prednisone for a lung or a heart condition or have you had Pulmonary Fibrosis or Cystic Fibrosis
Yes No
N/A  N/A   
In the 12 months prior to the effective date have you used nitroglycerine in any form (spray, patch or pill) for a heart condition for the relief of angina or chest pain
Yes No
N/A  N/A   
In the 6 months prior to the effective date have you been hospitalized or visited an Emergency Room for any circulatory disorder, heart/cardiovascular, stroke/cerebrovascular, neurological, lung/respiratory condition, digestive/gastro-intestinal/liver/kidney disorder, Diabetes or Cancer
Yes No
N/A  N/A   
In the 3 months prior to the effective date have you required assistance for daily living (meaning assistance with getting in or out of bed, eating, dressing, bathing and toilet)
Yes No
N/A  N/A   
Have you had a Bone Marrow transplant, stem cell transplant or a major organ transplant (heart, lung, liver or kidney)
Yes No
N/A  N/A   
Do you have any Aneurysm not surgically repaired
Yes No
N/A  N/A 
I have read the above eligibility requirements. I understand them, and declare that I am eligible. I acknowledge that any policy and coverage provided to me on the basis of the answers given will be deemed null and void if any answer is not correct. I confirm I am eligible.
Yes No
N/A  N/A   
 
CIRCULATORY, VASCULAR OR BLOOD DISORDERS:
Have you been prescribed or taken medication, or diagnosed with or had an investigation, medical consultation or treatment in the last 5 years for the following conditions? Medications  Stability"Stable" means a medical condition for which:
  1. there has been NO increase in symptoms or development of new symptoms; NO test results showing deterioration,
  2. a Physician has not determined that the condition has become worse,
  3. a Physician has NOT recommended or prescribed a reduction, increase or stoppage in medication dosage or its frequency, or a change in Treatment,
  4. a Physician has NOT recommended or prescribed a new medication,
  5. You have NOT been Hospitalized or required medical consultation (other than a routine examination where NO medical signs or symptoms existed or were found during the exam), and
  6. You are NOT awaiting further investigation, or results thereof, for that medical condition.
 
 
High Blood Pressure (Hypertension) or Low Blood Pressure (Hypotension)
Yes No
 
High cholesterol
Yes No
 
Peripheral Vascular Disease (PVD) or Peripheral Artery Disease (PAD), Narrowing or blockage of any vein or artery (other than an artery of the heart), a blood clot in a vein or artery, Deep Vein Thrombosis (DVT), phlebitis, carotid stenosis not repaired by surgery, surgery to repair carotid artery, surgery to repair an aneurysm of any type, surgery to repair a narrowing or blockage of any vein or artery (other than artery of the heart)
Yes No
 
Oedema (edema) treated with a diuretic (water pill)
Yes No
 
A blood disorder for which you have been referred to a specialist or specialty clinic or required prescription medication or treatment
Yes No
 
 
CARDIOVASCULAR:
Have you ever been prescribed or taken medication, or diagnosed with or had an investigation, medical consultation or treatment for the following conditions? Medications  Stability"Stable" means a medical condition for which:
  1. there has been NO increase in symptoms or development of new symptoms; NO test results showing deterioration,
  2. a Physician has not determined that the condition has become worse,
  3. a Physician has NOT recommended or prescribed a reduction, increase or stoppage in medication dosage or its frequency, or a change in Treatment,
  4. a Physician has NOT recommended or prescribed a new medication,
  5. You have NOT been Hospitalized or required medical consultation (other than a routine examination where NO medical signs or symptoms existed or were found during the exam), and
  6. You are NOT awaiting further investigation, or results thereof, for that medical condition.
 
 
Disorders of the heart rhythm or conduction including atrial fibrillation, arrhythmia and bundle branch block, pacemaker, ablation or cardioverter-defibrillator (ICD) implanted less than 10 years ago
Yes No
 
Heart attack (Myocardial infarction), Arteriosclerosis, Chest pain, Angina, or Coronary artery disease (CAD) or surgery for angioplasty, stent or bypass less than 12 years ago
Yes No
 
Surgery for Heart by-pass, Angioplasty or Stent 12 or more years ago
Yes No
 
Heart murmur, valvular heart disorder or valve surgery performed less than 10 years ago
Yes No
 
Valve surgery 10 or more years ago or a cardioverter-defibrillator (ICD) implanted 10 or more years ago
Yes No
 
Cardiomyopathy, Congestive heart failure or water on the lungs or the use of Lasix or Furosemide
Yes No
 
Other heart/cardiovascular problems including congenital heart disorders
Yes No
 
 
CEREBROVASCULAR OR NEUROLOGICAL:
Have you ever been prescribed or taken medication, or diagnosed with or had an investigation, medical consultation or treatment for the following conditions? Medications  Stability"Stable" means a medical condition for which:
  1. there has been NO increase in symptoms or development of new symptoms; NO test results showing deterioration,
  2. a Physician has not determined that the condition has become worse,
  3. a Physician has NOT recommended or prescribed a reduction, increase or stoppage in medication dosage or its frequency, or a change in Treatment,
  4. a Physician has NOT recommended or prescribed a new medication,
  5. You have NOT been Hospitalized or required medical consultation (other than a routine examination where NO medical signs or symptoms existed or were found during the exam), and
  6. You are NOT awaiting further investigation, or results thereof, for that medical condition.
 
 
Stroke, Cerebrovascular accident (CVA), Mini Stroke, Transient ischemic attack (TIA)CVAs are caused by a blood clot interrupting the blood flow to the brain (ischemic CVA) or by the rupture of a blood vessel or of an aneurysm (haemorrhagic CVA). Since the interruption is prolonged, the client could be left with permanent sequels. Anomalies will appear on cerebral imaging (scans, MRIs etc). A TIA is a sudden neurological deficiency, which disappears in less than an hour and leaves no traceable imaging anomalies. A TIA is an early sign of a potential cerabrovascular accident (CVA), which does leave permanent lesions.
Yes No
 
Syncope or dizzy spells or fainting that was reported to a doctor or hospital
Yes No
 
Dementia or Alzheimer's~disease
Yes No
 
Other Cerebrovascular or Neurological conditions or disorders (see the Key Terms document)
Yes No
 
 
RESPIRATORY:
Have you been prescribed or taken medication, or diagnosed with or had an investigation, medical consultation or treatment in the last 5 years for the following conditions? Medications  Stability"Stable" means a medical condition for which:
  1. there has been NO increase in symptoms or development of new symptoms; NO test results showing deterioration,
  2. a Physician has not determined that the condition has become worse,
  3. a Physician has NOT recommended or prescribed a reduction, increase or stoppage in medication dosage or its frequency, or a change in Treatment,
  4. a Physician has NOT recommended or prescribed a new medication,
  5. You have NOT been Hospitalized or required medical consultation (other than a routine examination where NO medical signs or symptoms existed or were found during the exam), and
  6. You are NOT awaiting further investigation, or results thereof, for that medical condition.
 
 
COPD, Emphysema, Chronic Bronchitis, Chronic PneumoniaCOPD collectively describes a series of respiratory conditions characterised by the obstruction or the limitation or air flow. The main conditions are chronic bronchitis and emphysema.
Yes No
 
Asthma with inhaler/puffer, except a minor ailmentAsthma is an inflammation of the bronchia resulting in an oedema and the shrinking of the respiratory tract and causing breathing difficulties. Asthma is a chronic condition.
Yes No
 
Other chronic respiratory condition, lung disorder or lung surgery (not including minor ailments)If there is a removal of any portion of the lung you must check other lung condition.
Yes No
 
 
KIDNEY, GASTRO-INTESTINAL, DIGESTIVE OR LIVER:
Have you been prescribed or taken medication, or diagnosed with or had an investigation, medical consultation or treatment in the last 5 years for the following conditions? Medications  Stability"Stable" means a medical condition for which:
  1. there has been NO increase in symptoms or development of new symptoms; NO test results showing deterioration,
  2. a Physician has not determined that the condition has become worse,
  3. a Physician has NOT recommended or prescribed a reduction, increase or stoppage in medication dosage or its frequency, or a change in Treatment,
  4. a Physician has NOT recommended or prescribed a new medication,
  5. You have NOT been Hospitalized or required medical consultation (other than a routine examination where NO medical signs or symptoms existed or were found during the exam), and
  6. You are NOT awaiting further investigation, or results thereof, for that medical condition.
 
 
Any stomach, bowel, digestive, gastrointestinal disorder for which you have been referred to a GI specialist or specialty clinic or that has required prescription medication or surgery (Exception: GERD, Diverticulosis and routine colonoscopies; see the Key Terms document)Diverticulosis are small bags (diverticulae) that appear on the walls of the colon. Diverticulitis is an inflammation of the diverticulae resulting from an infection. Ulcerated colitis is a chronic inflammatory condition that affects the colon and the rectum. Intestinal bleeding identifies any blood loss through the gastro-intestinal tract (from the mouth to the anus).
Yes No
 
Liver disorder/Spleen/Pancreas/Gall Bladder disorder, Gall stones not eliminated. Answer NO to this question if the Gall Bladder is removedCirrhosis is an irreversible chronic condition of the liver. It results from prolonged abuse of liver cells (alcoholism, viruses, medication). Hepatitis is used to describe any accute or chronic inflammation of the liver. Severe hepatitis can lead to the destruction of the liver and death. There are several forms of hepatitis identified as A, B, C, D and E. Pancreatitis is an inflamation of the pancreas usually caused by excessive alcohol consumption or by billiary calculi (stones). Pancreatitis comes in 2 variations: acute and chronic. Biliary calculi are made of chrystallised cholesterol. They can obstruct the biliary conducts that carry the bile to the liver and the intestines.
Yes No
 
Kidney disorder, Kidney stones not eliminated, 2 or more bladder or urinary track infections in the last 12 months or a Catheter implant
Yes No
 
 
DIABETES:
Have you been prescribed or taken medication, or diagnosed with or had an investigation, medical consultation or treatment in the last 5 years for the following? Medications  Stability"Stable" means a medical condition for which:
  1. there has been NO increase in symptoms or development of new symptoms; NO test results showing deterioration,
  2. a Physician has not determined that the condition has become worse,
  3. a Physician has NOT recommended or prescribed a reduction, increase or stoppage in medication dosage or its frequency, or a change in Treatment,
  4. a Physician has NOT recommended or prescribed a new medication,
  5. You have NOT been Hospitalized or required medical consultation (other than a routine examination where NO medical signs or symptoms existed or were found during the exam), and
  6. You are NOT awaiting further investigation, or results thereof, for that medical condition.
 
 
Diabetes prescribed insulinIf insulin and oral medications are taken, both conditions (Diabetes with insulin and Diabetes with medication) have to be checked.
Yes No
 
Diabetes prescribed oral medication (not insulin)If insulin and oral medications are taken, both conditions (Diabetes with insulin and Diabetes with medication) have to be checked.
Yes No
 
Diabetes without medication or impaired glucose toleranceThere is no surcharge for this condition.
Yes No
 
 
CANCER:
Have you ever been prescribed or taken medication, or diagnosed with or had an investigation, medical consultation or treatment for the following? Medications  Stability"Stable" means a medical condition for which:
  1. there has been NO increase in symptoms or development of new symptoms; NO test results showing deterioration,
  2. a Physician has not determined that the condition has become worse,
  3. a Physician has NOT recommended or prescribed a reduction, increase or stoppage in medication dosage or its frequency, or a change in Treatment,
  4. a Physician has NOT recommended or prescribed a new medication,
  5. You have NOT been Hospitalized or required medical consultation (other than a routine examination where NO medical signs or symptoms existed or were found during the exam), and
  6. You are NOT awaiting further investigation, or results thereof, for that medical condition.
 
 
Leukemia or Lymphoma or Multiple Myeloma
Yes No
 
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 cancerIf there is a removal of any portion of the lung you must check other lung condition.
Yes No
 
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)
Yes No
N/A  N/A   
 
OTHER ELIGIBILITY OR RISK FACTORS:
Have you been prescribed or taken medication, or diagnosed with or had an investigation, medical consultation or treatment for the following? Medications  Stability"Stable" means a medical condition for which:
  1. there has been NO increase in symptoms or development of new symptoms; NO test results showing deterioration,
  2. a Physician has not determined that the condition has become worse,
  3. a Physician has NOT recommended or prescribed a reduction, increase or stoppage in medication dosage or its frequency, or a change in Treatment,
  4. a Physician has NOT recommended or prescribed a new medication,
  5. You have NOT been Hospitalized or required medical consultation (other than a routine examination where NO medical signs or symptoms existed or were found during the exam), and
  6. You are NOT awaiting further investigation, or results thereof, for that medical condition.
 
 
In the 24 months prior to the effective date have you smoked or used tobacco products
Yes No
N/A  N/A   
In the 6 months prior to the effective date have you received advice/treatment for a medical emergency in a hospital emergency room two or more times
Yes No
N/A  N/A   
In the 6 months prior to the effective date have you had two or more falls that were reported to a physician
Yes No
N/A  N/A   
In the 12 months prior to the effective date have you been referred to a specialist or specialty clinic or required treatment or prescription medication or surgery for any other medical or physical disorder or condition not referred to above
Yes No
 

Notes 
Please enter any additional, pertinent information and any other information relating to your health here: (500 characters)

I confirm that I have followed the instructions set out below:

  1. I have reviewed my answer to each question to ensure that I have answered each question truthfully, accurately and completely so that SRMRM can accurately calculate premium appropriate for my health status,

  2. I selected the number of medications that I am taking for each medical condition (be sure the total number of medications that you are taking is correct) and then

  3. I selected the period my medical condition has been Stable since the last occurrence of any new or change in symptom, investigation, consultation, new or change in medication, new or change in Treatment, or Hospitalization that I had for each condition.