Health insurance covers up to $200000. Please read the policy before filling out the application.This product is underwritten by Industrial Alliance Insurance and Financial Services Inc.
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| What is your birth date?
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TRAVEL AND TRIP INFORMATION
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| Effective Date of this policy | |
| Termination Date of this policy | |
| OR Duration of coverage | days |
| Coverage Details: |
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Application Type? A monthly billing option is only available for Super Visa, Visitor (365 days minimum).
For shorter trips, select Visitor, Immigrant, Returning Canadian.
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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? |
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Note: Family denotes two adults plus dependants, Couple denotes two adults only.
The Birth Date of the eldest member must be used above. |
| Health Coverage: (Choose the desired limit) |
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| Do you want Accidental Death coverage? (optional) |
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starting from $30.00 to $176.63 depending on age |
| Allowances: |
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| Have you purchased a policy from us last year?
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| Is your travelling companion insured by us? (Receive a 5% allowance.)
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Companion's name: |
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ELIGIBILITY: |
You must meet the Eligibility Requirements set out below to be eligible for coverage under this policy. You are eligible for coverage if:
- 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
- You are currently in good health, You do not have any recent signs or symptoms that are undiagnosed, You have not been hospitalized for a sickness in the last six months, and You know of no reason why You would require Treatment during Your Policy Period; and
- You are not residing in a nursing home, rest home, convalescent home, rehabilitation centre or home for the aged or required assistance with any activities of daily living (bathing, eating, using a toilet, taking medication(s) or getting into or out of a chair or bed) where you reside in Canada; and
- 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; and
- In the 12 months prior to the effective date you have not:
- been prescribed home oxygen or prednisone for a lung condition or a heart condition or had Pulmonary Fibrosis or Cystic Fibrosis;
- 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%;
- had any aneurysm that is not surgically repaired;
- been treated in a hospital for anemia requiring iron supplements or blood transfusion;
- 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.
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| Notes |
| Please enter any additional, pertinent information and any other information relating to your health here: |
(500 characters) |
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PRE-EXISTING CONDITIONS ARE NOT COVERED WITH THIS APPLICATION.
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