GMS Visitor Medical Declaration - Danforth Insurance

Q1. Do you have any reason to seek medical treatment, excluding the regular care of a chronic condition or medical evaluation required to satisfy travel visa requirements?

Applicant 1 (age: 41)

Applicant 2 (age: 41)

Applicant 3 (age: 41)

Applicant 4 (age: 41)

Applicant 5 (age: 41)

Q2. If you are currently in Canada, have you ever been denied similar coverage offered by another Canadian insurer? Select No if you are currently not in Canada.

Applicant 1 (age: 41)

Applicant 2 (age: 41)

Applicant 3 (age: 41)

Applicant 4 (age: 41)

Applicant 5 (age: 41)

Q3. If you are currently in Canada, have you had more than $5,000 in medical treatment in the last 12 months while in Canada? Select No if you are currently not in Canada.

Applicant 1 (age: 41)

Applicant 2 (age: 41)

Applicant 3 (age: 41)

Applicant 4 (age: 41)

Applicant 5 (age: 41)

Q4. Are you:

expecting medical treatment for heart disease;
waiting for a test(s) for a suspected heart condition; and/or
taking prescription drugs for heart disease while taking insulin to treat diabetes?

Applicant 1 (age: 41)

Applicant 2 (age: 41)

Applicant 3 (age: 41)

Applicant 4 (age: 41)

Applicant 5 (age: 41)

Q5. Do you have an Implantable Cardioverter Defibrillator (ICD)?

Applicant 1 (age: 41)

Applicant 2 (age: 41)

Applicant 3 (age: 41)

Applicant 4 (age: 41)

Applicant 5 (age: 41)

Q6. Have you fainted or fallen more than once without medical diagnosis (syncope)?

Applicant 1 (age: 41)

Applicant 2 (age: 41)

Applicant 3 (age: 41)

Applicant 4 (age: 41)

Applicant 5 (age: 41)

Q7. Do you use home oxygen for a medical condition?

Applicant 1 (age: 41)

Applicant 2 (age: 41)

Applicant 3 (age: 41)

Applicant 4 (age: 41)

Applicant 5 (age: 41)

Q8. Do you take oral steroids to treat a lung condition?

Applicant 1 (age: 41)

Applicant 2 (age: 41)

Applicant 3 (age: 41)

Applicant 4 (age: 41)

Applicant 5 (age: 41)

Q9. Are you being treated for cancer or have Metastatic Cancer?

Applicant 1 (age: 41)

Applicant 2 (age: 41)

Applicant 3 (age: 41)

Applicant 4 (age: 41)

Applicant 5 (age: 41)

Q10. Do you have a vascular aneurysm that is surgically untreated?

Applicant 1 (age: 41)

Applicant 2 (age: 41)

Applicant 3 (age: 41)

Applicant 4 (age: 41)

Applicant 5 (age: 41)

Q11. Have you ever had:

a valve replacement,
kidney (renal) dialysis, or
an organ transplant?

Applicant 1 (age: 41)

Applicant 2 (age: 41)

Applicant 3 (age: 41)

Applicant 4 (age: 41)

Applicant 5 (age: 41)

Q12. Were you diagnosed; did you receive new medical treatment
(e.g. consultation, tests or prescription drugs); or have you had a change in your medical treatment, (e.g. a stop, start or dosage change to a prescription drug, other than a dosage change of Coumadin or Warfarin) for, any of the following conditions in the last twelve (12) months:

CongestiveHeartFailure
Atrial flutter
Atrial/ventricularfibrillation
Peripheral vascular disease
Stroke/transient ischemic attack (TIA)
Acquired Immune Deficiency Syndrome (AIDS)
Terminal Illness
Blood Clot(s)
Gastrointestinal Bleeding

Applicant 1 (age: 41)

Applicant 2 (age: 41)

Applicant 3 (age: 41)

Applicant 4 (age: 41)

Applicant 5 (age: 41)

Q13. Do you need help from another person(s) with activities of daily living (ADL)?

Applicant 1 (age: 41)

Applicant 2 (age: 41)

Applicant 3 (age: 41)

Applicant 4 (age: 41)

Applicant 5 (age: 41)

Declaration

Completing the Eligibility section of this application accurately is very important. It includes medical questions that determine you can purchase a plan. The Exclusions to Coverage section of this policy lists specific expenses that are not covered. Here are important examples of these:

1. GMS does not cover any expenses or complications related to:

Pregnancy, abortion, miscarriage, or childbirth.

2. GMS does not cover expenses resulting from pre-existing medical conditions which have not been stable for 180 days.

To review the full list and details of the exclusions, Click here.

I/We (“I”) declare the statements made herein are true and complete and shall form part of my application for coverage. I hereby authorize any physician, health care provider, other person, hospital, institution, or insurance company to release to Group Medical Services and/or its authorized agents, representatives, affiliates or other service providers (collectively “GMS”) any information covering my medical history, symptoms, treatment, examination, diagnosis and/or services rendered to myself or any of my dependants herein listed.

For the purposes of administering any Group Medical Services (“GMS”) benefits, products or services (collectively “benefits”) and/or determining eligibility for benefits, I authorize GMS to: (a) collect, store and use any personal information which I have provided to GMS or personal information obtained pursuant to clause (b); and/or (b) obtain personal information about me (or any other person listed herein) from, or disclose such personal information to: my Government Health Insurance Plan; the operator of any hospital, clinic, or other health facility; a doctor or other health care provider; any insurance company; or any other service provider or third party as may be reasonably required for the purposes described above.

I understand that, whether before or after my application, any misrepresentation, incorrect or concealed information or failure to fully complete all sections of the application may void my coverage. I declare that, if I am signing on behalf of any person(s), I have the authority to sign on behalf of such person(s) listed herein and confirm that each of the above declarations and authorizations are also provided on behalf of such person(s).

I warrant that neither I, nor any person herein listed, have any additional coverage through any insurer other than the information listed herein. Should I, or any person herein listed, subsequently obtain additional coverage through any insurer, while covered under this contract, I will immediately advise GMS in writing. I hereby authorize GMS to coordinate any eligible expenses with any additional insurer that I, or any person herein listed, may have coverage under.

Do you agree to the declaration?

Yes

No