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Pankaj Bhatia

1 (647) 640-8400

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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
Coverage Details:    
Application Type?
Super Visa must be purchased for 365 days; a monthly billing option is available.
For shorter trips, select Visitor, Immigrant, Returning Canadian.



Note: Super Visa requires a single application for each party.

Note: This applies only if you are a student registered at a Canadian School.
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.
Coverage: (Choose the desired limit)  
Country of origin or last residence:  
Allowances:    
Have you purchased a policy from us last year?
 
Is your travelling companion insured by us? (Receive a 5% allowance.)
Companion's name:
Name of your Beneficiary: Relationship:

STEP 2 : 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) ELIGIBILITY. SEE STEP 3 AT THE BOTTOM OF THE PAGE:
     
a) I have read the eligibility requirements at the bottom of the application and in the Policy documents. I confirm I am eligible.
N/A  N/A   
 
2) Have you had CIRCULATORY, VASCULAR OR BLOOD DISORDERS in the last 3 years?:
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) or Low Blood Pressure (Hypotension)
 
b) Vascular Disease (PVD) or Artery Disease (PAD)
 
 
3) Have you ever had symptoms or diagnosis for HEART OR CARDIOVASCULAR 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) Cardiomyopathy, Congestive heart failure or water on the lungs or the use of Lasix or Furosemide
 
b) Other heart/cardiovascular problems including congenital heart disorders
 
 
4) Have you ever had symptoms or diagnosis for STROKE, CEREBROVASCULAR OR NEUROLOGICAL 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) Other Cerebrovascular or Neurological conditions or disorders
 
 
5) Have you had RESPIRATORY OR LUNG conditions in the last 3 years?:
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) Any chronic respiratory condition, lung disorder or lung surgery. (not including minor ailments)
 
 
6) Have you had KIDNEY, GASTRO-INTESTINAL, DIGESTIVE OR LIVER conditions in the last 3 years?:
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 Kidney Disease, Chronic Renal Failure, Pancreatitis, Hepatitis or Cirrhosis of the liver
 
b) Other gastro-intestinal/liver/kidney conditions
 
 
7) Have you had DIABETES in the last 3 years?:
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 oral medications are taken, both conditions (Diabetes with insulin and Diabetes with medication) have to be checked.
 
c) Diabetes without medication or impaired glucose toleranceThere is no surcharge for this condition.
 
 
8) Have you ever had CANCER?:
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 and not including basal cell or squamous cell skin cancer
 
c) In the 6 months prior to the effective date have you had chemotherapy or radiation therapy for cancer or malignant tumour(s)
 
 
9) Do you have any OTHER RISK FACTORS you would like to be covered?:
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) Have you had symptoms, 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 - list them in the note section
 
b) Syncope or dizzy spells or fainting that was reported to a doctor or hospital
 
c) 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   
d) In the 6 months prior to the effective date have you received advice/treatment for a medical emergency in a hospital for any of the conditions listed above
N/A  N/A   

STEP 3 : ELIGIBILITY:

You must meet the Eligibility Requirements set out below to be eligible for coverage under this policy. You are eligible for coverage if:
  1. You are at least 15 days old and You are age 89 or under and not insured or eligible for benefits under a Canadian Government Health Insurance Plan; and
  2. You know of no reason why you would require medical attention during your trip; and
  3. In the 12 months prior to the effective date you have not:
    1. been prescribed home oxygen or prednisone for a lung condition or a heart condition or had Pulmonary Fibrosis or Cystic Fibrosis;
    2. 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%;
    3. had any aneurysm that is not surgically repaired;
  4. You have not had a Bone Marrow transplant, stem cell transplant or an organ transplant except a cornea transplant.
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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