INSURE LIFE FINANCIAL GROUP INC.

For Travel Outside of Canada - Value Plan, No PreEx

Health insurance covers up to $2000000. Please read the policy before filling out the application.

This product is underwritten by Industrial Alliance Insurance and Financial Services Inc.

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 for Multi-trip annual, combo or single trip

Add-ons (Optional):

Is this a Top-up of an HMC policy, or are you extending another insurance coverage?To top-up or extend coverage of an annual plan, or to purchase coverage after the departure.

Click Yes and enter the Departure Date (i.e., the date you left or intend to leave Canada,)
Enter the Effective Date for the desired extension,
Enter the Termination Date or the Duration of the coverage you wish to purchase.

Yes No

If it is a Top-up, what is the Departure date from Canada? Enter the date you left or intend to leave Canada; it must preceed the the Effective date of this policy.

Coverage Details:

Who is the coverage for?

Note: Family denotes oldest adult plus dependants. (All must be eligible.)

Do you require coverage in the USA or Mexico? (If "No", save 15%)

Yes No

Do you have a history of medical conditions Circulatory, Vascular or Blood disorders;
Heart or Cardiovascular;
Stroke, Cerebrovascular or Neurological;
Respiratory or Lung;
Diabetes ? (If "No", save 15%)

Yes, I have a history of medical conditions that I do not want covered.
No, I do not have a history of any medical conditions other than minor ailments.

Allowances:

Early bird savings? (available May 1 - Oct 23)

Yes No

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 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. You know of no reason why you would require medical attention during your trip. In the 12 months prior to the effective date of coverage you have not: had a diagnosis of a terminal illness; 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 been advised by any physician that travelling on your trip would be medically unsafe or that you should not travel on your trip. You have not had an organ transplant (excluding a corneal transplant.) If you cannot meet all of the above Eligibility Requirements any time you depart on your trip(s), you are not eligible for coverage under this policy. I confirm I am eligible.

Notes

Please enter any additional, pertinent information and any other information relating to your health here:

(500 characters)

Available Actions:

INSURE LIFE FINANCIAL GROUP INC.

1 (604) 518-7300

Health insurance covers up to $2000000. Please read the policy before filling out the application.

STEP 1: TRAVEL AND TRIP INFORMATION

STEP 2 : ELIGIBILITY: