Medical Declaration
All applicants of age 60 or above are required to complete the medical questionnaire.
Please answer the following yes/no questions:
Eligibility – Medical Questionnaire (1 of 3)
This section determines if you are eligible to purchase insurance. If you answer “YES” to ANY of the following questions, you are not eligible to purchase the Travel Medical Emergency Plan and you will need to apply for the Individual Medical Underwriting Plan. Please contact us at +1-647-350-0332 to apply for the Individual Medical Underwriting Plan.
Q1. Have you had a heart bypass, coronary angioplasty or heart valve surgery more than ten(10) years ago? |
|
Q2. In the last three(3) years, have you been diagnosed with, taken or been prescribed medication, or been treated for any two (2) of the following? If you only have one (1) of the following conditions, answer “NO”.
|
|
| Q3. In the last two(2) years, have you: | |
a. Been diagnosed with, taken or been prescribed medication, or been treated for heart failure or congestive heart failure; and/or b. Been prescribed or taken Lasix or furosemide or a water pill for ankle or leg swelling or water on the lungs? |
|
| Q4. In the last twelve(12) months, have you had: | |
| a. A new heart condition, or had an existing heart condition for which you had a change in medication or were hospitalized (as an inpatient or seen in the emergency department); and/or |
|
b. Shortness of breath or chest pain for which you sought treatment; and/or |
|
c. Cancer or received chemotherapy and/or radiotherapy and/or other treatment, other than routine follow-up, for cancer (except basal cell and squamous cell skin cancer, and breast cancer treated only with hormonal therapy)? |
|
d. A lung condition for which you were hospitalized(as an inpatient or seen in the emergency department) or for which you have been prescribed or taken prednisone? |
|
Q5.In the last four(4) months, have you been prescribed or taken six(6) or more prescription medications? Do not count the following medications: hormone replacement therapy (thyroid or menopausal); drugs used for osteoporosis or traveller’s diarrhea; or any form of immunization. Do not count topical medications that go in your nose, ears or eyes or on your scalp or skin except any form of nitroglycerine or any drug(s) for angina. |
Q1. Have you had a heart bypass, coronary angioplasty or heart valve surgery more than ten(10) years ago? |
|
Q2. In the last three(3) years, have you been diagnosed with, taken or been prescribed medication, or been treated for any two (2) of the following? If you only have one (1) of the following conditions, answer “NO”.
|
|
| Q3. In the last two(2) years, have you: | |
a. Been diagnosed with, taken or been prescribed medication, or been treated for heart failure or congestive heart failure; and/or b. Been prescribed or taken Lasix or furosemide or a water pill for ankle or leg swelling or water on the lungs? |
|
| Q4. In the last twelve(12) months, have you had: | |
| a. A new heart condition, or had an existing heart condition for which you had a change in medication or were hospitalized (as an inpatient or seen in the emergency department); and/or |
|
b. Shortness of breath or chest pain for which you sought treatment; and/or |
|
c. Cancer or received chemotherapy and/or radiotherapy and/or other treatment, other than routine follow-up, for cancer (except basal cell and squamous cell skin cancer, and breast cancer treated only with hormonal therapy)? |
|
d. A lung condition for which you were hospitalized(as an inpatient or seen in the emergency department) or for which you have been prescribed or taken prednisone? |
|
Q5.In the last four(4) months, have you been prescribed or taken six(6) or more prescription medications? Do not count the following medications: hormone replacement therapy (thyroid or menopausal); drugs used for osteoporosis or traveller’s diarrhea; or any form of immunization. Do not count topical medications that go in your nose, ears or eyes or on your scalp or skin except any form of nitroglycerine or any drug(s) for angina. |
Q1. Have you had a heart bypass, coronary angioplasty or heart valve surgery more than ten(10) years ago? |
|
Q2. In the last three(3) years, have you been diagnosed with, taken or been prescribed medication, or been treated for any two (2) of the following? If you only have one (1) of the following conditions, answer “NO”.
|
|
| Q3. In the last two(2) years, have you: | |
a. Been diagnosed with, taken or been prescribed medication, or been treated for heart failure or congestive heart failure; and/or b. Been prescribed or taken Lasix or furosemide or a water pill for ankle or leg swelling or water on the lungs? |
|
| Q4. In the last twelve(12) months, have you had: | |
| a. A new heart condition, or had an existing heart condition for which you had a change in medication or were hospitalized (as an inpatient or seen in the emergency department); and/or |
|
b. Shortness of breath or chest pain for which you sought treatment; and/or |
|
c. Cancer or received chemotherapy and/or radiotherapy and/or other treatment, other than routine follow-up, for cancer (except basal cell and squamous cell skin cancer, and breast cancer treated only with hormonal therapy)? |
|
d. A lung condition for which you were hospitalized(as an inpatient or seen in the emergency department) or for which you have been prescribed or taken prednisone? |
|
Q5.In the last four(4) months, have you been prescribed or taken six(6) or more prescription medications? Do not count the following medications: hormone replacement therapy (thyroid or menopausal); drugs used for osteoporosis or traveller’s diarrhea; or any form of immunization. Do not count topical medications that go in your nose, ears or eyes or on your scalp or skin except any form of nitroglycerine or any drug(s) for angina. |
Q1. Have you had a heart bypass, coronary angioplasty or heart valve surgery more than ten(10) years ago? |
|
Q2. In the last three(3) years, have you been diagnosed with, taken or been prescribed medication, or been treated for any two (2) of the following? If you only have one (1) of the following conditions, answer “NO”.
|
|
| Q3. In the last two(2) years, have you: | |
a. Been diagnosed with, taken or been prescribed medication, or been treated for heart failure or congestive heart failure; and/or b. Been prescribed or taken Lasix or furosemide or a water pill for ankle or leg swelling or water on the lungs? |
|
| Q4. In the last twelve(12) months, have you had: | |
| a. A new heart condition, or had an existing heart condition for which you had a change in medication or were hospitalized (as an inpatient or seen in the emergency department); and/or |
|
b. Shortness of breath or chest pain for which you sought treatment; and/or |
|
c. Cancer or received chemotherapy and/or radiotherapy and/or other treatment, other than routine follow-up, for cancer (except basal cell and squamous cell skin cancer, and breast cancer treated only with hormonal therapy)? |
|
d. A lung condition for which you were hospitalized(as an inpatient or seen in the emergency department) or for which you have been prescribed or taken prednisone? |
|
Q5.In the last four(4) months, have you been prescribed or taken six(6) or more prescription medications? Do not count the following medications: hormone replacement therapy (thyroid or menopausal); drugs used for osteoporosis or traveller’s diarrhea; or any form of immunization. Do not count topical medications that go in your nose, ears or eyes or on your scalp or skin except any form of nitroglycerine or any drug(s) for angina. |
Q1. Have you had a heart bypass, coronary angioplasty or heart valve surgery more than ten(10) years ago? |
|
Q2. In the last three(3) years, have you been diagnosed with, taken or been prescribed medication, or been treated for any two (2) of the following? If you only have one (1) of the following conditions, answer “NO”.
|
|
| Q3. In the last two(2) years, have you: | |
a. Been diagnosed with, taken or been prescribed medication, or been treated for heart failure or congestive heart failure; and/or b. Been prescribed or taken Lasix or furosemide or a water pill for ankle or leg swelling or water on the lungs? |
|
| Q4. In the last twelve(12) months, have you had: | |
| a. A new heart condition, or had an existing heart condition for which you had a change in medication or were hospitalized (as an inpatient or seen in the emergency department); and/or |
|
b. Shortness of breath or chest pain for which you sought treatment; and/or |
|
c. Cancer or received chemotherapy and/or radiotherapy and/or other treatment, other than routine follow-up, for cancer (except basal cell and squamous cell skin cancer, and breast cancer treated only with hormonal therapy)? |
|
d. A lung condition for which you were hospitalized(as an inpatient or seen in the emergency department) or for which you have been prescribed or taken prednisone? |
|
Q5.In the last four(4) months, have you been prescribed or taken six(6) or more prescription medications? Do not count the following medications: hormone replacement therapy (thyroid or menopausal); drugs used for osteoporosis or traveller’s diarrhea; or any form of immunization. Do not count topical medications that go in your nose, ears or eyes or on your scalp or skin except any form of nitroglycerine or any drug(s) for angina. |
Smoking – Medical Questionnaire (2 of 3)
Q. In the last two(2) years, have you smoked cigarettes and/or used vaping products or e-cigarettes? |
Q. In the last two(2) years, have you smoked cigarettes and/or used vaping products or e-cigarettes? |
Q. In the last two(2) years, have you smoked cigarettes and/or used vaping products or e-cigarettes? |
Q. In the last two(2) years, have you smoked cigarettes and/or used vaping products or e-cigarettes? |
Q. In the last two(2) years, have you smoked cigarettes and/or used vaping products or e-cigarettes? |
Premiums Rate Qualification – Medical Questionnaire (3 of 3)
| Q1. Have you ever been diagnosed with or treated for: | |
| a. A heart condition; and/or |
|
b. Any of the following conditions?
|
|
Q2. In the last three(3) months, have you been prescribed or taken a total of three(3) or more medications for high blood pressure (hypertension)? |
|
| Q3. In the last five(5) years, have you been diagnosed with, taken or been prescribed medication, or been treated for any of the following? | |
| a. Lung condition except unrepeated prescription medications used for a single episode (medication includes any puffers/inhalers) |
|
b. Stroke/CVA (cerebrovascular accident) or mini-stroke/TIA (transient ischemic attack) (medication includes use of aspirin/Entrophen for this condition); |
|
c. Diabetes (treated with medication and/or insulin); |
|
d. Narrowed or blocked artery in the legs or in the neck |
| Q1. Have you ever been diagnosed with or treated for: | |
| a. A heart condition; and/or |
|
b. Any of the following conditions?
|
|
Q2. In the last three(3) months, have you been prescribed or taken a total of three(3) or more medications for high blood pressure (hypertension)? |
|
| Q3. In the last five(5) years, have you been diagnosed with, taken or been prescribed medication, or been treated for any of the following? | |
| a. Lung condition except unrepeated prescription medications used for a single episode (medication includes any puffers/inhalers) |
|
b. Stroke/CVA (cerebrovascular accident) or mini-stroke/TIA (transient ischemic attack) (medication includes use of aspirin/Entrophen for this condition); |
|
c. Diabetes (treated with medication and/or insulin); |
|
d. Narrowed or blocked artery in the legs or in the neck |
| Q1. Have you ever been diagnosed with or treated for: | |
| a. A heart condition; and/or |
|
b. Any of the following conditions?
|
|
Q2. In the last three(3) months, have you been prescribed or taken a total of three(3) or more medications for high blood pressure (hypertension)? |
|
| Q3. In the last five(5) years, have you been diagnosed with, taken or been prescribed medication, or been treated for any of the following? | |
| a. Lung condition except unrepeated prescription medications used for a single episode (medication includes any puffers/inhalers) |
|
b. Stroke/CVA (cerebrovascular accident) or mini-stroke/TIA (transient ischemic attack) (medication includes use of aspirin/Entrophen for this condition); |
|
c. Diabetes (treated with medication and/or insulin); |
|
d. Narrowed or blocked artery in the legs or in the neck |
| Q1. Have you ever been diagnosed with or treated for: | |
| a. A heart condition; and/or |
|
b. Any of the following conditions?
|
|
Q2. In the last three(3) months, have you been prescribed or taken a total of three(3) or more medications for high blood pressure (hypertension)? |
|
| Q3. In the last five(5) years, have you been diagnosed with, taken or been prescribed medication, or been treated for any of the following? | |
| a. Lung condition except unrepeated prescription medications used for a single episode (medication includes any puffers/inhalers) |
|
b. Stroke/CVA (cerebrovascular accident) or mini-stroke/TIA (transient ischemic attack) (medication includes use of aspirin/Entrophen for this condition); |
|
c. Diabetes (treated with medication and/or insulin); |
|
d. Narrowed or blocked artery in the legs or in the neck |
| Q1. Have you ever been diagnosed with or treated for: | |
| a. A heart condition; and/or |
|
b. Any of the following conditions?
|
|
Q2. In the last three(3) months, have you been prescribed or taken a total of three(3) or more medications for high blood pressure (hypertension)? |
|
| Q3. In the last five(5) years, have you been diagnosed with, taken or been prescribed medication, or been treated for any of the following? | |
| a. Lung condition except unrepeated prescription medications used for a single episode (medication includes any puffers/inhalers) |
|
b. Stroke/CVA (cerebrovascular accident) or mini-stroke/TIA (transient ischemic attack) (medication includes use of aspirin/Entrophen for this condition); |
|
c. Diabetes (treated with medication and/or insulin); |
|
d. Narrowed or blocked artery in the legs or in the neck |
Additional information required
| Q1. In the last two(2) years, have you been diagnosed with, taken or been prescribed medication, or treated for any of the following conditions? | |
| a. Gastrointestinal bleeding or bowel obstruction or have had bowel surgery |
|
b. Chronic bowel disorder such as, but not limited to, Crohn’s disease or ulcerativecolitis; |
|
| c. Kidney disorder (including stones) or liver disorder or pancreatitis; |
|
| d. Gallbladder disorder (including stones) not applicable if gallbladder has been removed). | |
Q2. In the last two(2) years, have you been diagnosed with and/or treated by a hematologist or an internist for a blood disorder? |
|
Q3. Are you age 71 or older and in the last 6 months, have you had a fall for which you sought medical attention? |
|
Q4. In the last six(6) months, have you received advice or treatment in the emergency room of a hospital three (3) or more times? |
| Q1. In the last two(2) years, have you been diagnosed with, taken or been prescribed medication, or treated for any of the following conditions? | |
| a. Gastrointestinal bleeding or bowel obstruction or have had bowel surgery |
|
b. Chronic bowel disorder such as, but not limited to, Crohn’s disease or ulcerativecolitis; |
|
| c. Kidney disorder (including stones) or liver disorder or pancreatitis; |
|
| d. Gallbladder disorder (including stones) not applicable if gallbladder has been removed). | |
Q2. In the last two(2) years, have you been diagnosed with and/or treated by a hematologist or an internist for a blood disorder? |
|
Q3. Are you age 71 or older and in the last 6 months, have you had a fall for which you sought medical attention? |
|
Q4. In the last six(6) months, have you received advice or treatment in the emergency room of a hospital three (3) or more times? |
| Q1. In the last two(2) years, have you been diagnosed with, taken or been prescribed medication, or treated for any of the following conditions? | |
| a. Gastrointestinal bleeding or bowel obstruction or have had bowel surgery |
|
b. Chronic bowel disorder such as, but not limited to, Crohn’s disease or ulcerativecolitis; |
|
| c. Kidney disorder (including stones) or liver disorder or pancreatitis; |
|
| d. Gallbladder disorder (including stones) not applicable if gallbladder has been removed). | |
Q2. In the last two(2) years, have you been diagnosed with and/or treated by a hematologist or an internist for a blood disorder? |
|
Q3. Are you age 71 or older and in the last 6 months, have you had a fall for which you sought medical attention? |
|
Q4. In the last six(6) months, have you received advice or treatment in the emergency room of a hospital three (3) or more times? |
| Q1. In the last two(2) years, have you been diagnosed with, taken or been prescribed medication, or treated for any of the following conditions? | |
| a. Gastrointestinal bleeding or bowel obstruction or have had bowel surgery |
|
b. Chronic bowel disorder such as, but not limited to, Crohn’s disease or ulcerativecolitis; |
|
| c. Kidney disorder (including stones) or liver disorder or pancreatitis; |
|
| d. Gallbladder disorder (including stones) not applicable if gallbladder has been removed). | |
Q2. In the last two(2) years, have you been diagnosed with and/or treated by a hematologist or an internist for a blood disorder? |
|
Q3. Are you age 71 or older and in the last 6 months, have you had a fall for which you sought medical attention? |
|
Q4. In the last six(6) months, have you received advice or treatment in the emergency room of a hospital three (3) or more times? |
| Q1. In the last two(2) years, have you been diagnosed with, taken or been prescribed medication, or treated for any of the following conditions? | |
| a. Gastrointestinal bleeding or bowel obstruction or have had bowel surgery |
|
b. Chronic bowel disorder such as, but not limited to, Crohn’s disease or ulcerativecolitis; |
|
| c. Kidney disorder (including stones) or liver disorder or pancreatitis; |
|
| d. Gallbladder disorder (including stones) not applicable if gallbladder has been removed). | |
Q2. In the last two(2) years, have you been diagnosed with and/or treated by a hematologist or an internist for a blood disorder? |
|
Q3. Are you age 71 or older and in the last 6 months, have you had a fall for which you sought medical attention? |
|
Q4. In the last six(6) months, have you received advice or treatment in the emergency room of a hospital three (3) or more times? |