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CVIS Canadian Reg. Man.


MRM Travel Insurance - CUMIS Standard Plan

Health insurance covers up to $5,000,000. Please read the policy before filling out the application.


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 for Multi-trip annual, combo or single trip
Add-ons (Optional):    
Is this a Top-up? (Are you extending another insurance coverage? Have you already departed on your trip?)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 the Effective date of this policy. (yyyy-mm-dd)
Coverage details:    
Allowances:    
Have you purchased a policy from SRMRM last year?
Yes No
 
Early bird savings? (available Jun 1 - Oct 31)
Yes No
 
Is your travelling companion insured by SRMRM? (Receive a 5% allowance.)
Yes No
Companion's name:

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

 
This plan requires the medical questionnaire to be filled out.
 

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 Click here to view the Key Terms used in the Application. Key terms are italicized

Current Medications

The medical condition has been Stable for

 
1) ELIGIBILITY:
If you answer Yes to one of the questions in this section you are not eligible for coverage under this policy.      
a) 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   
b) 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   
c) 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   
d) 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   
e) 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, or do you have a Cardiac condition with an ejection fraction of LESS THAN 40%
Yes No
N/A  N/A   
f) 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   
g) 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   
h) 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   
i) Do you have any Aneurysm not surgically repaired
Yes No
N/A  N/A   
j) 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   
 
2) 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 3 years for the following conditions? Current Medications  Condition has been Stable for"Stable" means that during the specified period:
  1. there has been no new treatment; and
  2. there has been no change in treatment or change in treatment frequency or type; and
  3. there have been no signs or symptoms or new diagnosis; and
  4. there has been no hospitalization; and
  5. there has been no referral to a specialist (made or recommended) and you are not awaiting the results of further investigations performed by any medical professional.
Exceptions:
  1. the routine adjustment of Coumadin, warfarin, or insulin (as long as the medication is not first prescribed or stopped during the 90 days prior to the effective date);
  2. change from a brand name medication to a generic medication provided the medication was not first prescribed during 90 days prior to the effective date and there is no increase or decrease in dosage;
  3. a minor ailment.
 
 
a) High Blood Pressure (Hypertension) or Low Blood Pressure (Hypotension)
Yes No
 
b) High cholesterol
Yes No
 
c) 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
 
d) Oedema (edema) treated with a diuretic (water pill)
Yes No
 
e) A blood disorder for which you have been referred to a specialist or specialty clinic or required prescription medication or treatment
Yes No
 
 
3) CARDIOVASCULAR:
Have you ever been prescribed or taken medication, or diagnosed with or had an investigation, medical consultation or treatment for the following conditions? Current Medications  Condition has been Stable for"Stable" means that during the specified period:
  1. there has been no new treatment; and
  2. there has been no change in treatment or change in treatment frequency or type; and
  3. there have been no signs or symptoms or new diagnosis; and
  4. there has been no hospitalization; and
  5. there has been no referral to a specialist (made or recommended) and you are not awaiting the results of further investigations performed by any medical professional.
Exceptions:
  1. the routine adjustment of Coumadin, warfarin, or insulin (as long as the medication is not first prescribed or stopped during the 90 days prior to the effective date);
  2. change from a brand name medication to a generic medication provided the medication was not first prescribed during 90 days prior to the effective date and there is no increase or decrease in dosage;
  3. a minor ailment.
 
 
a) Disorders of the heart rhythm or conduction including atrial fibrillation, arrhythmia, pacemaker, ablation or cardioverter-defibrillator (ICD) implanted less than 10 years ago
Yes No
 
b) 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
 
c) Surgery for Heart by-pass, Angioplasty or Stent 12 or more years ago
Yes No
 
d) Heart murmur, valvular heart disorder or valve surgery performed less than 10 years ago
Yes No
 
e) Valve surgery 10 or more years ago or a cardioverter-defibrillator (ICD) implanted 10 or more years ago
Yes No
 
f) Cardiomyopathy, Congestive heart failure or water on the lungs or the use of Lasix or Furosemide
Yes No
 
g) Other heart/cardiovascular problems including congenital heart disorders
Yes No
 
 
4) 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? Current Medications  Condition has been Stable for"Stable" means that during the specified period:
  1. there has been no new treatment; and
  2. there has been no change in treatment or change in treatment frequency or type; and
  3. there have been no signs or symptoms or new diagnosis; and
  4. there has been no hospitalization; and
  5. there has been no referral to a specialist (made or recommended) and you are not awaiting the results of further investigations performed by any medical professional.
Exceptions:
  1. the routine adjustment of Coumadin, warfarin, or insulin (as long as the medication is not first prescribed or stopped during the 90 days prior to the effective date);
  2. change from a brand name medication to a generic medication provided the medication was not first prescribed during 90 days prior to the effective date and there is no increase or decrease in dosage;
  3. a minor ailment.
 
 
a) 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
 
b) Syncope or dizzy spells or fainting that was reported to a doctor or hospital
Yes No
 
c) Dementia or Alzheimer's disease
Yes No
 
d) Other Cerebrovascular or Neurological conditions or disorders (see the Key Terms document)
Yes No
 
 
5) RESPIRATORY:
Have you been prescribed or taken medication, or diagnosed with or had an investigation, medical consultation or treatment in the last 3 years for the following conditions? Current Medications  Condition has been Stable for"Stable" means that during the specified period:
  1. there has been no new treatment; and
  2. there has been no change in treatment or change in treatment frequency or type; and
  3. there have been no signs or symptoms or new diagnosis; and
  4. there has been no hospitalization; and
  5. there has been no referral to a specialist (made or recommended) and you are not awaiting the results of further investigations performed by any medical professional.
Exceptions:
  1. the routine adjustment of Coumadin, warfarin, or insulin (as long as the medication is not first prescribed or stopped during the 90 days prior to the effective date);
  2. change from a brand name medication to a generic medication provided the medication was not first prescribed during 90 days prior to the effective date and there is no increase or decrease in dosage;
  3. a minor ailment.
 
 
a) 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
 
b) 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
 
c) 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
 
 
6) 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 3 years for the following conditions? Current Medications  Condition has been Stable for"Stable" means that during the specified period:
  1. there has been no new treatment; and
  2. there has been no change in treatment or change in treatment frequency or type; and
  3. there have been no signs or symptoms or new diagnosis; and
  4. there has been no hospitalization; and
  5. there has been no referral to a specialist (made or recommended) and you are not awaiting the results of further investigations performed by any medical professional.
Exceptions:
  1. the routine adjustment of Coumadin, warfarin, or insulin (as long as the medication is not first prescribed or stopped during the 90 days prior to the effective date);
  2. change from a brand name medication to a generic medication provided the medication was not first prescribed during 90 days prior to the effective date and there is no increase or decrease in dosage;
  3. a minor ailment.
 
 
a) 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
 
b) 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
 
c) Kidney disorder, Kidney stones not eliminated, 2 or more bladder or urinary tract infections in the last 12 months or a Catheter implant
Yes No
 
 
7) DIABETES:
Have you been prescribed or taken medication, or diagnosed with or had an investigation, medical consultation or treatment in the last 3 years for the following? Current Medications  Condition has been Stable for"Stable" means that during the specified period:
  1. there has been no new treatment; and
  2. there has been no change in treatment or change in treatment frequency or type; and
  3. there have been no signs or symptoms or new diagnosis; and
  4. there has been no hospitalization; and
  5. there has been no referral to a specialist (made or recommended) and you are not awaiting the results of further investigations performed by any medical professional.
Exceptions:
  1. the routine adjustment of Coumadin, warfarin, or insulin (as long as the medication is not first prescribed or stopped during the 90 days prior to the effective date);
  2. change from a brand name medication to a generic medication provided the medication was not first prescribed during 90 days prior to the effective date and there is no increase or decrease in dosage;
  3. a minor ailment.
 
 
a) Diabetes prescribed insulinIf insulin and oral medications are taken, both conditions (Diabetes with insulin and Diabetes with medication) have to be checked.
Yes No
 
b) 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
 
c) Diabetes without medication or impaired glucose toleranceThere is no surcharge for this condition.
Yes No
 
 
8) CANCER:
Have you ever been prescribed or taken medication, or diagnosed with or had an investigation, medical consultation or treatment for the following? Current Medications  Condition has been Stable for"Stable" means that during the specified period:
  1. there has been no new treatment; and
  2. there has been no change in treatment or change in treatment frequency or type; and
  3. there have been no signs or symptoms or new diagnosis; and
  4. there has been no hospitalization; and
  5. there has been no referral to a specialist (made or recommended) and you are not awaiting the results of further investigations performed by any medical professional.
Exceptions:
  1. the routine adjustment of Coumadin, warfarin, or insulin (as long as the medication is not first prescribed or stopped during the 90 days prior to the effective date);
  2. change from a brand name medication to a generic medication provided the medication was not first prescribed during 90 days prior to the effective date and there is no increase or decrease in dosage;
  3. a minor ailment.
 
 
a) Leukemia or Lymphoma or Multiple Myeloma
Yes No
 
b) 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
 
c) 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   
 
9) 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? Current Medications  Condition has been Stable for"Stable" means that during the specified period:
  1. there has been no new treatment; and
  2. there has been no change in treatment or change in treatment frequency or type; and
  3. there have been no signs or symptoms or new diagnosis; and
  4. there has been no hospitalization; and
  5. there has been no referral to a specialist (made or recommended) and you are not awaiting the results of further investigations performed by any medical professional.
Exceptions:
  1. the routine adjustment of Coumadin, warfarin, or insulin (as long as the medication is not first prescribed or stopped during the 90 days prior to the effective date);
  2. change from a brand name medication to a generic medication provided the medication was not first prescribed during 90 days prior to the effective date and there is no increase or decrease in dosage;
  3. a minor ailment.
 
 
a) In the 24 months prior to the effective date have you smoked or used tobacco products
Yes No
N/A  N/A   
b) 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   
c) 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   
d) 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
N/A   

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.

Key Terms Used in this Application

Answers on the application: Each condition requires you to answer either "Yes" or "No" depending on whether you have had such a condition, including signs or symptoms or investigation or medical consultation concerning a certain condition. If the condition has been specifically ruled out and no further follow-up action has been or needs to be taken then you can answer "No" to the condition. If you answer "Yes" to any condition, you must state how many medications you are taking for that condition and for how long the condition has been stable. This information will help to determine if your condition may be covered. If you have too many medications for major conditions they may be excluded from coverage.

Auto-immune disorder includes acquired immune deficiency syndrome (AIDS) or human immunodeficiency virus (HIV), Grave's disease, Lou Gehrig's disease, multiple sclerosis, myasthenia gravis, sarcoidosis any location, scleroderma, systematic lupus erythematosis.

Blood Disorder includes anemia (other than vitamin B-12 deficiency anemia), hemochromatosis, idiopathic thrombocytopenic purpura (ITP), hemophilia, polycythemia vera, Sickle-cell anemia.

Emergency means an unexpected or unforeseeable sickness or injury which requires immediate medical attention or treatment to prevent or alleviate existing danger to life or health, or to relieve acute symptoms, that cannot be delayed until you return to your province.

Major organ means, heart, kidney, liver or lung.

Medical consultation means any medical services obtained from a licensed medical practitioner for a sickness, injury or medical condition, including but not limited to any or all of: history taking, medical examination, investigative testing, advice or treatment, and during which a diagnosis of the condition need not have been definitively made. This does not include regular medical check-ups where no medical signs or symptoms existed between check-ups or were found during the check-up.

Minor Ailment means any sickness or injury which does not require:

  1. the use of medication for a period greater than 15 days;
  2. more than one follow-up visit to a physician;
  3. hospitalization, surgical intervention, or referral to a specialist; and
  4. which ends at least thirty (30) days prior to your effective date.
A chronic condition or any complication thereof is not considered a minor ailment; it is a pre-existing condition.

Other Cerebrovascular or Neurological conditions or disorders: includes Parkinson's disease, epilepsy, cerebral palsy, multiple sclerosis, brain injury or brain tumor, seizure disorder, Lou Gehrig's disease (ALS), Creutzfeldt-Jakob disease, Cushing's syndrome, Guillain-Barré syndrome (GBS), trigeminal neuralgia (TN or TGN).

Pre-existing condition means a medical or physical condition, symptom, illness or disease, whether diagnosed or not, for which treatment has been received or taken, or which exhibited signs or symptoms, at any time preceding your effective date and includes a medically recognized complication or recurrence of a medical condition but does not include a minor ailment.

Recurrence means the appearance of signs or symptoms caused by or related to a medical condition which was previously diagnosed by a physician or for which treatment was previously received.

Signs or symptoms means any evidence of disease experienced by you or recognized through observation.

Stable as indicated on your medical statement summary (if applicable), means that during the specified period:

  1. there has been no new treatment; and
  2. there has been no change in treatment or change in treatment frequency or type; and
  3. there have been no signs or symptoms or new diagnosis; and
  4. there have been no test results showing deterioration; and
  5. there has been no hospitalization; and
  6. there has been no referral to a specialist (made or recommended) and you are not awaiting the results of further investigations performed by any medical professional.
Exceptions:
  1. the routine adjustment of Coumadin, warfarin, or insulin (as long as the medication is not first prescribed or stopped during the 90 days prior to the effective date);
  2. change from a brand name medication to a generic medication provided the medication was not first prescribed during 90 days prior to the effective date and there is no increase or decrease in dosage;
  3. a minor ailment.

Stomach, bowel, digestive, gastrointestinal disorder includes any condition along the gastrointestinal tract (from the mouth to the anus) and can include (among others) esophagus disorder, stomach disorder, ulcer, hernia, irritable bowel syndrome (IBS), inflammatory bowel disease, gastrointestinal bleeds, gastritis, Chrohn's disease, Celiac disease, diverticulitis, ulcerative colitis, colitis, bowel obstruction, bowel resection or ostomy.

Exceptions: The following conditions are not subject to any surcharge but must be noted in the note section of the medical questionnaire:

  1. Gastroesophageal reflux disease (GERD); or
  2. removal of polyps during a routine colonoscopy where no signs or symptoms were present; or
  3. diverticulosis.

Terminal applies to a medical condition for which a physician gave a prognosis of eventual death or for which palliative care was received prior to the effective date.

Treatment means a medical, therapeutic or diagnostic procedure prescribed, performed or recommended by a physician including, but not limited to, prescribed medication, investigative testing or surgery.