insurelifefg_norm.jpg

INSURE LIFE FINANCIAL GROUP INC.

1 (604) 518-7300

ingleassurance.jpg

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.
What is your birth date? 

TRAVEL AND TRIP INFORMATION

Effective Date of this policy
Termination Date of this policy
OR Duration of coverage days
Coverage Details:    
Application Type? A monthly billing option is only available for Super Visa, Visitor (365 days minimum).
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.
Health Coverage: (Choose the desired limit)  
Do you want Accidental Death coverage? (optional) starting from $30.00 to $176.63 depending on age
Allowances:    
Have you purchased a policy from us last year?
 
Is your travelling companion insured by us? (Receive a 5% allowance.)
Companion's name:
     
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
No: Losses related to Covid-19 are not covered

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 are currently in good health, You do not have any recent signs or symptoms that are undiagnosed, You have 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
  3. 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
  4. 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
  5. 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. been treated in a hospital for anemia requiring iron supplements or blood transfusion;
  6. 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)

PRE-EXISTING CONDITIONS ARE NOT COVERED WITH THIS APPLICATION.


Available Actions: