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Manulife Financial

Out of Province Travel Insurance for Canadians

Who can apply:

TO BE ELIGIBLE FOR INSURANCE UNDER THIS POLICY, you must be at least 30 days of age and a resident of Canada covered by the Government Health Insurance Plan in your province of residence for the entire trip length.

 

Eligibility and Medical Questionnaire

Applicant :  Name      Age  

Single-Trip Medical Plan          Annual Multi-Trip Medical Plan    

Total Number of days per trip      (4, 10, 18, 30 and 60 days for Annual Multi-trip  plans)

   * If you are topping-up your existing policy, please provide the details in section Notes below

 

Section 1 - Eligibility

Please answer the following medical questions to determine your eligibility.

     On the date you apply for this coverage and on the effective date:

 

1

Have you been advised by a physician not to travel at this time?

 Yes No

2

Do you have a terminal illness for which a physician has estimated you have less than six (6) months to live?

 Yes No

3

Do you have metastatic cancer (a cancer that has spread from the original site to one or more other areas of the body)?

 Yes  No

4

Do you require kidney dialysis?

 Yes  No

5

Have you been prescribed or used home oxygen in the last twelve (12) months?

 Yes  No

6

Have you had a bone marrow, stem cell or organ transplant (excluding corneal transplant) ?

 Yes   No

If you must answer YES to any of the medical questions in Section 1, you are not eligible to purchase this policy. Please continue to Section 2, if you have to answer NO to all questions in Section 1.

 

Section 2 - Declaration

I am eligible to apply for this policy. I declare that all the information I am providing on this application is true and complete. I understand the meaning of treatment/treated, as defined and used in this questionnaire.

 

I understand that this coverage is subject to terms, conditions, limitations and exclusions (including the pre-existing condition exclusion); and, that this coverage 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, other medical service provider or any other organization or person that has any records or knowledge of me or my health to release to the assistance and claims service provider and/or Manulife and its reinsurers any such information for the purpose of this application and contract and any subsequent claim.

Please confirm :     Yes       No

 

 

Applicants 60 year of age or older must answer the following questions to determine eligibility and rate category.

IF YOU ARE UNCERTAIN OF YOUR ANSWERS TO ANY OF THE MEDICAL QUESTIONS, PLEASE CONSULT YOUR DOCTOR BEFORE COMPLETING THIS APPLICATION FOR TRAVEL INSURANCE

Section 3 - Do you require Individual Medical Underwriting?

1

Have you had a heart bypass, angioplasty or heart valve surgery more than ten (10) years ago?

 Yes  No

2

In the last three (3) years, have you been diagnosed with, taken or been prescribed medication, or been treated for any two (2) of the following? (if you only have one (1) of the following conditions, answer NO)

•   Heart condition;
• Lung condition (except unrepeated prescription medications used for a single episode) (medication includes any puffer(s)/inhaler(s));
• 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)

Yes   No

3

In the last two (2)years, have you been:

a) diagnosed with, taken or been prescribed medication, or been treated for heart failure or congestive heart failure, and/or

Yes  No

b) prescribed or taken Lasix or Furosemide or a water pill for heart failure, ankle or leg swelling, or water on the lungs?

Yes  No

4

    In the last twelve (12) months, have you had:

a) 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); and/or

 Yes  No

b) investigative testing or treatment for shortness of breath or chest pain; and/or

 Yes  No

c) a lung condition for which you were hospitalized (as an in-patient or in the emergency department)or for witch you have been prescribed or taken Prednisone; and/or

Yes  No

d) 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)?

Yes  No

5 

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.

 

 Yes   No

 

 

Section 4 - Smoker Status

1

In the last two (2) years, have you smoked cigarettes?

Yes   No

 

 

Section 5 - Rate Category Qualification

1

Have you EVER been diagnosed with or treated for:

a) Heart condition 

Yes    No

b)  Aortic aneurysm (including thoracic or abdominal aneurism)

Yes    No

c) Cirrhosis of the liver

Yes    No

d) Parkinson's disease

Yes    No

e) Alzheimer's disease or other form of dementia. Yes    No

2

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) ?

 Yes    No

3

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?

a)  Lung condition (except unrepeated prescription medications used for single episode) (medication includes any puffer(s)/inhaler(s));

Yes    No

b)  Stroke/CVA (cerebrovascular accident) or mini-stroke/TIA (transient ischemic attack)(including use of aspirin/Entrophen for this condition);

Yes    No

c)  Diabetes (if treated with medication and/or insulin);

Yes    No

d)  Narrowed or blocked artery in the legs (also called Peripheral Vascular Disease).

Yes    No

 

 

 

Section 6 - Rate Category Qualification

1

In the last two (2) years, have you been diagnosed with, taken or been prescribed medication, or treated for any of the following conditions?

1a

• Bowel obstruction OR have had bowel surgery;

 Yes     No

1b

• Gastrointestinal bleeding;

Yes     No

1c

• Chronic bowel disorder (such as but not limited to Crohn's disease or Ulcerative colitis);

Yes   No

1d

• Liver disorder;

Yes   No

1e

• Pancreatitis;

 Yes    No

1f

• Kidney disorder (including stones);

Yes    No

1g

• Gallbladder disorder (including stones. Not applicable if gallbladder has been removed.)

Yes   No

 

 

 

Section 7 - Rate Category Qualification

1

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?

Yes   No

2 

Are you over 70, and have you had a fall for which you sought medical attention  in the last six (6) months?

Yes    No

3

In the last six (6) months, have you received advice or treatment for a medical emergency more than twice in the emergency room of a hospital?  

Yes   N

 

 

 

Notes

(Please enter your phone number, if you want an insurance broker call you)

 

 

Your E-mail   

 

 

Definitions

Treatment, Treated means hospitalization, prescribed medications (including medication prescribed "as needed"), medical, therapeutic, diagnostic or surgical procedure prescribed, performed or recommended by a licensed medical practitioner. IMPORTANT:  Any reference to testing, tests, test results, or investigation excludes genetic tests."Genetic test" means a test that analyzes DNA, RNA or chromosomes for purposed such as the prediction of disease or vertical transmission risks, or monitoring, diagnosis prognosis

 

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Revised: January 04, 2018