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CVIS Canadian Reg. Man.

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What is your birth date? 

STEP 1: TRAVEL AND TRIP INFORMATION

Effective Date of this policy
Termination Date of this policy
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.
Departure date from Canada: Enter the date you left or intend to leave Canada; it must preceed the Effective date of this policy.
Coverage Details:    
Family, Couple or Single Coverage?
Note: Family denotes two adults plus dependants, Couple denotes two adults only.
The Birth Date of the eldest member must be used above.
Scroll for more dependants.
Are you a visitor to Canada covered under HMC?
 
Do you require coverage in the USA or Mexico? (If "No", save 20%)
 
Allowances:    
Is your travelling companion insured by us? (Receive a 5% allowance.)
Companion's name:
Did you have a travel insurance claim in the last 3 years?
 

STEP 2 : 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.

 
1) ELIGIBILITY:
See Step 3.      
a) I have read the eligibility requirements at the bottom of the application and in the Policy documents. I confirm I am eligible.
  1. You are a Canadian resident insured and covered under your Government Health Insurance Plan (GHIP),
  2. You are present in Canada when you purchase this policy and are not covered under GHIP and you agree to accept an additional deductible of $500 U.S. on each claim,
  3. You know of no reason why you would require medical attention during your trip,
  4. In the 6 months prior to the effective date you have not been hospitalized or visited an emergency room for any of the following:
    1. a circulatory disorder including blood clots;
    2. a heart or cardiovascular condition;
    3. a stroke or cerebrovascular accident or TIA;
    4. a neurological disorder;
    5. a lung or respiratory condition;
    6. a digestive or gastro-intestinal condition;
    7. a liver, or kidney disorder; or
    8. diabetes or cancer
  5. In the 12 months prior to the effective date you have not:
    1. had a diagnosis of Stage 3 or Stage 4 cancer, had cancer that has metastasized, or received treatment for pancreatic cancer or liver cancer;
    2. had a diagnosis of a terminal illness;
    3. been prescribed home oxygen or prednisone for a lung condition or a heart condition or had Pulmonary Fibrosis or Cystic Fibrosis;
    4. been diagnosed with or received treatment for Stage IV or Stage V Kidney Disease, kidney disease requiring dialysis or Cirrhosis of the Liver;
    5. used nitroglycerine in any form (spray, patch or pill) for a heart condition for the relief of angina or chest pain, or have a heart condition with an ejection fraction of LESS THAN 40%;
    6. had any aneurysm that is not surgically repaired;
    7. been a resident in a long-term care facility or in an assisted living facility where you were helped with any activities of daily living (bathing, eating, using a toilet, taking medication(s) or getting into or out of a chair or bed); or
    8. been advised by any physician that travelling on your trip would be medically unsafe or that you should not travel on your trip.
  6. You have not had a Bone Marrow transplant, stem cell transplant or an organ transplant except a cornea transplant,
  7. You have not:
    1. had a coronary angioplasty or stent insertion in the past 6 months; or
    2. in the past 12 months, received treatment for or taken medication for Congestive Heart Failure (CHF).
N/A  N/A   
 
2) CIRCULATORY, VASCULAR OR BLOOD DISORDERS:
In the last 3 years have you been diagnosed with, treated for or been prescribed or taken medication 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.
 
 
a) High Blood Pressure (Hypertension), Low Blood Pressure (Hypotension) or Edema (Oedema)
 
b) Peripheral Vascular Disease (PVD) (excluding varicose veins and venous stasis)
 
c) Carotid stenosis of 50% or more not repaired by surgery
 
d) Blood clot(s)
 
 
3) HEART / CARDIOVASCULAR:
Have you ever been diagnosed with, treated for or been prescribed or taken medication 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.
 
 
a) Disorders of the heart rhythm or conduction including atrial fibrillation, arrhythmia and bundle branch block or a pacemaker implant
 
b) Heart attack (Myocardial infarction), Arteriosclerosis, Chest pain, Angina, or Coronary artery disease (CAD) (answer NO if a bypass, angioplasty or stent was inserted after your last heart attack)
 
c) Surgery for Heart by-pass, Angioplasty or Stent less than 12 years ago
 
d) Surgery for Heart by-pass, Angioplasty or Stent 12 or more years ago
 
e) Valvular heart disorder or last surgery less than 8 years ago
 
f) Valvular heart surgery or an implanted cardioverter-defibrillator (ICD) 8 or more years ago
 
g) Any other heart/cardiovascular conditions not listed above
 
 
4) STROKE / CEREBROVASCULAR OR NEUROLOGICAL:
Have you ever been diagnosed with, treated for or been prescribed or taken medication 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.
 
 
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.
 
b) Syncope or dizzy spells or fainting that was reported to a doctor or hospital
 
c) Dementia or Alzheimer's disease
 
d) Parkinson's disease, epilepsy, muscular dystrophy, cerebral palsy, multiple sclerosis and myasthenia gravis
 
 
5) RESPIRATORY / LUNG:
In the last 3 years have you been diagnosed with, treated for or been prescribed or taken medication 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.
 
 
a) Chronic Obstructive Pulmonary Disease (COPD), chronic bronchitis, emphysema or asbestosis.
 
b) Other chronic respiratory condition, lung disorder, lung surgery or a removal of any portion of the lung. (This does not include seasonal allergies or a minor ailment)
 
 
6) KIDNEY, GASTRO-INTESTINAL, DIGESTIVE OR LIVER:
In the last 3 years have you been diagnosed with, treated for or been prescribed or taken medication 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.
 
 
a) Bowel condition including ulcerative colitis, Crohn's disease, diverticulitis, bowel obstruction, bowel surgery, chronic constipation, Irritable Bowel Syndrome (IBS) or gastrointestinal bleed
 
b) Hepatitis C
 
c) Kidney disorder, pancreatitis, kidney stones not eliminated, gall stones not eliminated (answer NO if gall bladder is removed), 2 or more bladder or urinary tract infections in the last 12 months.
 
 
7) DIABETES:
In the last 3 years have you been diagnosed with, treated for or been prescribed or taken medication 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.
 
 
a) Diabetes prescribed insulinIf insulin and oral medications are taken, both conditions (Diabetes with insulin and Diabetes with medication) have to be checked.
 
b) Diabetes prescribed medication (not insulin)If insulin and other prescribed medications are taken, both conditions (Diabetes with insulin and Diabetes with medication) have to be checked.
 
 
8) CANCER:
Have you ever been diagnosed with, treated for or been prescribed or taken medication 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.
 
 
a) Leukemia or Lymphoma or Multiple Myeloma
 
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.
 
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)
N/A  N/A   
 
9) OTHER RISK FACTORS:
In the last 3 years have you been diagnosed with, treated for or been prescribed or taken medication 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.
 
 
a) In the 24 months prior to the effective date have you smoked or used tobacco products
N/A  N/A   
b) Was your last complete medical examination more than 24 months ago
N/A  N/A   
c) 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
N/A  N/A   
d) In the 6 months prior to the effective date have you had two or more falls that were reported to a physician
N/A  N/A   

STEP 3 : ELIGIBILITY:

You must meet the Eligibility Requirements set out below any time you depart Canada on a Single Trip Plan or depart your province of residence on an Annual Multi-Trip Plan, to be eligible for coverage under this policy. You are eligible for coverage if:
  1. You are a Canadian resident insured and covered under your Government Health Insurance Plan (GHIP).
  2. You are present in Canada when you purchase this policy and are not covered under GHIP and you agree to accept an additional deductible of $500 U.S. on each claim.
  3. You know of no reason why you would require medical attention during your trip.
  4. In the 6 months prior to the effective date you have not been hospitalized or visited an emergency room for any of the following:
    1. a circulatory disorder including blood clots;
    2. a heart or cardiovascular condition;
    3. a stroke or cerebrovascular accident or TIA;
    4. a neurological disorder;
    5. a lung or respiratory condition;
    6. a digestive or gastro-intestinal condition;
    7. a liver, or kidney disorder; or
    8. diabetes or cancer.
  5. In the 12 months prior to the effective date you have not:
    1. had a diagnosis of Stage 3 or Stage 4 cancer, had cancer that has metastasized, or received treatment for pancreatic cancer or liver cancer;
    2. had a diagnosis of a terminal illness;
    3. been prescribed home oxygen or prednisone for a lung condition or a heart condition or had Pulmonary Fibrosis or Cystic Fibrosis;
    4. been diagnosed with or received treatment for Stage IV or Stage V Kidney Disease, kidney disease requiring dialysis or Cirrhosis of the Liver;
    5. used nitroglycerine in any form (spray, patch or pill) for a heart condition for the relief of angina or chest pain, or have a heart condition with an ejection fraction of LESS THAN 40%;
    6. had any aneurysm that is not surgically repaired;
    7. been a resident in a long-term care facility or in an assisted living facility where you were helped with any activities of daily living (bathing, eating, using a toilet, taking medication(s) or getting into or out of a chair or bed); or
    8. been advised by any physician that travelling on your trip would be medically unsafe or that you should not travel on your trip.
  6. You have not had a Bone Marrow transplant, stem cell transplant or an organ transplant except a cornea transplant.
  7. You have not:
    1. had a coronary angioplasty or stent insertion in the past 6 months; or
    2. in the past 12 months, received treatment for or taken medication for Congestive Heart Failure (CHF).
I have read the Eligibility Requirements above. 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.

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

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