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CVIS Canadian Reg. Man.

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A Single Application for All Plans for Travel Outside of Canada

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.
Do you require coverage in the USA or Mexico? (If "No", save 15%)
 
Allowances:    
     
Have you been vaccinated for COVID-19?
(the answer to this question determines COVID-19 related coverage)
Yes: Coverage up to $200,000 for the costs of medical care provided by hospitals and physicians and the cost of emergency return to Canada
No: Coverage up to $5,000,000 for outpatient diagnostic services and the cost of emergency return to Canada

STEP 2 : ELIGIBILITY:

You must meet the Eligibility Requirements set out below on the Effective Date of the policy to be eligible for coverage under this policy. You are eligible for coverage if:
  1. You are present in Canada when you purchase this policy and if you are not covered under your Government Health Insurance Plan (GHIP) you agree to accept an additional deductible of $500 U.S. on each claim.
  2. You know of no reason why you would require medical attention during your trip.
  3. 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;
    4. had Pulmonary Fibrosis, Cystic Fibrosis or Interstitial Lung Disease;
    5. been diagnosed with or received treatment for Stage IV or Stage V Kidney Disease, kidney disease requiring dialysis or Cirrhosis of the Liver;
    6. 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%;
    7. had a dilation of the aorta or any aneurysm that is not surgically repaired;
    8. 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
    9. been advised by any physician that travelling on your trip would be medically unsafe or that you should not travel on your trip.
  4. You have not had a Bone Marrow transplant, stem cell transplant or an organ transplant except a cornea transplant.
  5. You have not been treated for Aplastic anemia, Hemolytic anemia, Sickle cell anemia or anemia requiring blood transfusions or bone marrow transplants in the past 3 years. This does not include anemia related to iron and B-12 deficiencies;
  6. You have never received treatment for or taken medication for Heart Failure or 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.

STEP 3 : MEDICAL QUESTIONNAIRE - You MUST answer all questions, as your answers form the medical statement and become part of the policy. 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) CIRCULATORY, VASCULAR OR BLOOD DISORDERS:
In the last 3 years have you had, have been diagnosed with, treated for or been prescribed or taken medication for : 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), peripheral artery disease (PAD) or repaired aneurysm (excluding varicose veins and venous stasis)
 
c) Carotid stenosis of 50% or more not repaired by surgery
 
d) Anemia other than Aplastic anemia, Hemolytic anemia, Sickle cell anemia or anemia requiring blood transfusions or bone marrow transplants in the past 3 years
 
 
2) HEART OR CARDIOVASCULAR:
Have you ever been diagnosed with, treated for or been prescribed or taken medication for : 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 16 years ago
 
d) Surgery for Heart by-pass, Angioplasty or Stent 16 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 (describe in a note)
 
 
3) STROKE, CEREBROVASCULAR OR NEUROLOGICAL:
Have you ever been diagnosed with, treated for or been prescribed or taken medication for : 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, myasthenia gravis or other neurological conditions
 
 
4) RESPIRATORY OR LUNG:
In the last 3 years have you had, have been diagnosed with, treated for or been prescribed or taken medication for : 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 asthma, seasonal allergies or a minor ailment)
 
 
5) KIDNEY, GASTRO-INTESTINAL, DIGESTIVE OR LIVER:
In the last 3 years have you had, have been diagnosed with, treated for or been prescribed or taken medication for : 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 (ignore gall stones if the gall bladder was removed), 2 or more bladder or urinary tract infections in the last 12 months.
 
 
6) DIABETES:
In the last 3 years have you had, have been diagnosed with, treated for or been prescribed or taken medication for : 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.
 
 
7) CANCER:
Have you ever been diagnosed with, treated for or been prescribed or taken medication for : 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 (cannot be covered)
 
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   
 
8) OTHER RISK FACTORS:
In the last 3 years have you had, have been diagnosed with, treated for or been prescribed or taken medication for : 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) In the 12 months prior to the effective date have been prescribed or taken Lasix or Furosemide for any reason
N/A  N/A   
c) In the 6 months prior to the effective date have you received advice/treatment in a hospital for any of the conditions mentioned above in sections 2 through 8, or have you received advice/treatment in a hospital two or more times for any other medical condition (answer NO if the treatment was removal of the gall bladder or removal of kidney stones)
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   
Notes
Please enter any additional, pertinent information and any other information relating to your health here: (500 characters)

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