Ingle Assurance

 


What is person insured's birth date?   

STEP 1: TRAVEL AND TRIP INFORMATION
Effective Date of this policy
Termination Date of this policy
OR Duration of coverage days
Coverage Details:    
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.
Scroll for more dependants.
Health Coverage? (Choose the desired limit)  
Do you require coverage in the USA or Mexico? (If "No", save 15%)
 
Allowances (up to maximum 5%):    
Have you purchased a policy from us last year?
 
Will your travelling companion be insured by us? (Both get a 5% allowance.)
 
Companion's name?  
     

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 eligible for coverage if:
  1. 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.
  2. You know of no reason why you would require medical attention during your trip.
  3. In the 12 months prior to the effective date you have not:
    1. had a diagnosis of Stage 3 or Stage 4 cancer, had cancer that has metastasized, or received treatment for pancreatic cancer or liver cancer;
    2. had a diagnosis of a terminal illness;
    3. been prescribed home oxygen or prednisone for a lung condition or a heart condition;
    4. had Pulmonary Fibrosis, Cystic Fibrosis or Interstitial Lung Disease;
    5. been diagnosed with or received treatment for Stage IV or Stage V Kidney Disease, kidney disease requiring dialysis or Cirrhosis of the Liver;
    6. 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%;
    7. had a dilation of the aorta or any aneurysm that is not surgically repaired;
    8. 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
    9. been advised by any physician that travelling on your trip would be medically unsafe or that you should not travel on your trip.
  4. You have not had a Bone Marrow transplant, stem cell transplant or an organ transplant except a cornea transplant.
  5. 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;
  6. You have never received treatment for or taken medication for Heart Failure or Congestive Heart Failure (CHF).
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.

STEP 3 : MEDICAL QUESTIONNAIRE - You MUST answer all questions, as your answers form the medical statement and become part of the policy. You must click Yes for any condition that you had symptoms, been investigated for, received consultation or Treatment for, or had a change in medication or a change in Treatment for, been Hospitalized for or been diagnosed with.
  1. Check whether the stability clause is based on the Effective Date or the Application Date.
  2. If you have been prescribed medicine or a course of care by a doctor or have sought care from a licensed practitioner, you will be considered to have received treatment for a medical condition or injury.
  3. Certain underwriting rules may exclude a condition or reject the application.
  4. The policy is void if there is a material mistake in the medical statement.

 
1) ELIGIBILITY:
See Step 3.      
a) Have you been diagnosed with or received treatment for a Stage IV or Stage V Chronic Kidney Disease, kidney disease requiring dialysis or Cirrhosis of the Liver
N/A  N/A   
b) In the 12 months prior to the effective date have you been advised by a physician not to travel
N/A  N/A   
c) In the 12 months prior to the effective date have you been diagnosed with a terminal illness, Stage 3 or Stage 4 cancer, cancer that has metastasized, received treatment for pancreatic cancer, liver cancer, or have HIV, AIDS or AIDS-related complex
N/A  N/A   
d) In the 12 months prior to the effective date have you taken or been prescribed home oxygen or prednisone for a lung or a heart condition or have you had Pulmonary Fibrosis or Cystic Fibrosis
N/A  N/A   
e) In the 12 months prior to the effective date have you used nitroglycerine in any form (spray, patch or pill) for a heart condition for the relief of angina or chest pain
N/A  N/A   
f) In the 6 months prior to the effective date have you been hospitalized or visited an Emergency Room for any circulatory disorder, heart/cardiovascular, stroke/cerebrovascular, neurological, lung/respiratory condition, digestive/gastro-intestinal/liver/kidney disorder, Diabetes or Cancer
N/A  N/A   
g) In the 3 months prior to the effective date have you required assistance for daily living (meaning assistance with getting in or out of bed, eating, dressing, bathing and toilet)
N/A  N/A   
h) Have you had a Bone Marrow transplant, stem cell transplant or a major organ transplant (heart, lung, liver or kidney)
N/A  N/A   
i) Do you have any Aneurysm not surgically repaired
N/A  N/A 
j) I have read the eligibility requirements at the bottom of the application and in the Policy documents. I confirm I am eligible.
  1. You are a Canadian resident insured and covered under your Government Health Insurance Plan (GHIP),
  2. You are present in Canada when you purchase this policy and are not covered under GHIP and you agree to accept an additional deductible of $500 U.S. on each claim,
  3. You know of no reason why you would require medical attention during your trip,
  4. In the 6 months prior to the effective date you have not been hospitalized or visited an emergency room for any of the following:
    1. a circulatory disorder including blood clots;
    2. a heart or cardiovascular condition;
    3. a stroke or cerebrovascular accident or TIA;
    4. a neurological disorder;
    5. a lung or respiratory condition;
    6. a digestive or gastro-intestinal condition;
    7. a liver, or kidney disorder; or
    8. diabetes or cancer
  5. In the 12 months prior to the effective date you have not:
    1. had a diagnosis of Stage 3 or Stage 4 cancer, had cancer that has metastasized, or received treatment for pancreatic cancer or liver cancer;
    2. had a diagnosis of a terminal illness;
    3. been prescribed home oxygen or prednisone for a lung condition or a heart condition or had Pulmonary Fibrosis or Cystic Fibrosis;
    4. been diagnosed with or received treatment for Stage IV or Stage V Kidney Disease, kidney disease requiring dialysis or Cirrhosis of the Liver;
    5. 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%;
    6. had any aneurysm that is not surgically repaired;
    7. 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
    8. been advised by any physician that travelling on your trip would be medically unsafe or that you should not travel on your trip.
  6. You have not had a Bone Marrow transplant, stem cell transplant or an organ transplant except a cornea transplant,
  7. You have not:
    1. had a coronary angioplasty or stent insertion in the past 6 months; or
    2. in the past 12 months, received treatment for or taken medication for Congestive Heart Failure (CHF).
N/A  N/A   
 
2) CIRCULATORY, VASCULAR OR BLOOD DISORDERS:
In the last 3 years have you had, have been diagnosed with, treated for or been prescribed or taken medication for : Medications  Stability"Stable" means a medical condition for which:
  1. there has been NO increase in symptoms or development of new symptoms; NO test results showing deterioration,
  2. a Physician has not determined that the condition has become worse,
  3. a Physician has NOT recommended or prescribed a reduction, increase or stoppage in medication dosage or its frequency, or a change in Treatment,
  4. a Physician has NOT recommended or prescribed a new medication,
  5. You have NOT been Hospitalized or required medical consultation (other than a routine examination where NO medical signs or symptoms existed or were found during the exam), and
  6. You are NOT awaiting further investigation, or results thereof, for that medical condition.
 		  
a) High Blood Pressure (Hypertension) or Low Blood Pressure (Hypotension)
 
b) High cholesterol
 
c) Peripheral Vascular Disease (PVD) or Peripheral Artery Disease (PAD), Narrowing or blockage of any vein or artery (other than an artery of the heart), a blood clot in a vein or artery, Deep Vein Thrombosis (DVT), phlebitis, carotid stenosis not repaired by surgery, surgery to repair carotid artery, surgery to repair an aneurysm of any type, surgery to repair a narrowing or blockage of any vein or artery (other than artery of the heart)
 
d) Oedema (edema) treated with a diuretic (water pill)
 
e) A blood disorder for which you have been referred to a specialist or specialty clinic or required prescription medication or treatment
 
 
3) HEART OR CARDIOVASCULAR:
Have you ever been diagnosed with, treated for or been prescribed or taken medication for : Medications  Stability"Stable" means a medical condition for which:
  1. there has been NO increase in symptoms or development of new symptoms; NO test results showing deterioration,
  2. a Physician has not determined that the condition has become worse,
  3. a Physician has NOT recommended or prescribed a reduction, increase or stoppage in medication dosage or its frequency, or a change in Treatment,
  4. a Physician has NOT recommended or prescribed a new medication,
  5. You have NOT been Hospitalized or required medical consultation (other than a routine examination where NO medical signs or symptoms existed or were found during the exam), and
  6. You are NOT awaiting further investigation, or results thereof, for that medical condition.
 		  
a) Disorders of the heart rhythm or conduction including atrial fibrillation, arrhythmia and bundle branch block, pacemaker, ablation or cardioverter-defibrillator (ICD) implanted less than 10 years ago
 
b) Heart attack (Myocardial infarction), Arteriosclerosis, Chest pain, Angina, or Coronary artery disease (CAD) or surgery for angioplasty, stent or bypass less than 12 years ago
 
c) Surgery for Heart by-pass, Angioplasty or Stent 12 or more years ago
 
d) Heart murmur, valvular heart disorder or valve surgery performed less than 10 years ago
 
e) Valve surgery 10 or more years ago or a cardioverter-defibrillator (ICD) implanted 10 or more years ago
 
f) Cardiomyopathy, Congestive heart failure or water on the lungs or the use of Lasix or Furosemide
 
g) Any other heart/cardiovascular problems including chest pain, surgery or congenital heart disorders
 
 
4) STROKE, CEREBROVASCULAR OR NEUROLOGICAL:
Have you ever been diagnosed with, treated for or been prescribed or taken medication for : Medications  Stability"Stable" means a medical condition for which:
  1. there has been NO increase in symptoms or development of new symptoms; NO test results showing deterioration,
  2. a Physician has not determined that the condition has become worse,
  3. a Physician has NOT recommended or prescribed a reduction, increase or stoppage in medication dosage or its frequency, or a change in Treatment,
  4. a Physician has NOT recommended or prescribed a new medication,
  5. You have NOT been Hospitalized or required medical consultation (other than a routine examination where NO medical signs or symptoms existed or were found during the exam), and
  6. You are NOT awaiting further investigation, or results thereof, for that medical condition.
 		  
a) Stroke, Cerebrovascular accident (CVA), Mini Stroke, Transient ischemic attack (TIA)CVAs are caused by a blood clot interrupting the blood flow to the brain (ischemic CVA) or by the rupture of a blood vessel or of an aneurysm (haemorrhagic CVA). Since the interruption is prolonged, the client could be left with permanent sequels. Anomalies will appear on cerebral imaging (scans, MRIs etc). A TIA is a sudden neurological deficiency, which disappears in less than an hour and leaves no traceable imaging anomalies. A TIA is an early sign of a potential cerabrovascular accident (CVA), which does leave permanent lesions.
 
b) Syncope or dizzy spells or fainting that was reported to a doctor or hospital
 
c) Dementia or Alzheimer's disease
 
d) Other Cerebrovascular or Neurological conditions or disorders
 
 
5) RESPIRATORY OR LUNG:
In the last 3 years have you had, have been diagnosed with, treated for or been prescribed or taken medication for : Medications  Stability"Stable" means a medical condition for which:
  1. there has been NO increase in symptoms or development of new symptoms; NO test results showing deterioration,
  2. a Physician has not determined that the condition has become worse,
  3. a Physician has NOT recommended or prescribed a reduction, increase or stoppage in medication dosage or its frequency, or a change in Treatment,
  4. a Physician has NOT recommended or prescribed a new medication,
  5. You have NOT been Hospitalized or required medical consultation (other than a routine examination where NO medical signs or symptoms existed or were found during the exam), and
  6. You are NOT awaiting further investigation, or results thereof, for that medical condition.
 		  
a) COPD, Emphysema, Chronic Bronchitis, Chronic PneumoniaCOPD collectively describes a series of respiratory conditions characterised by the obstruction or the limitation or air flow. The main conditions are chronic bronchitis and emphysema.
 
b) Asthma with inhaler/puffer, except a minor ailmentAsthma is an inflammation of the bronchia resulting in an oedema and the shrinking of the respiratory tract and causing breathing difficulties. Asthma is a chronic condition.
 
c) Other chronic respiratory condition, lung disorder, lung surgery or a removal of any portion of the lung. (This does not include asthma, seasonal allergies or a minor ailment)
 
 
6) KIDNEY, GASTRO-INTESTINAL, DIGESTIVE OR LIVER:
In the last 3 years have you had, have been diagnosed with, treated for or been prescribed or taken medication for : Medications  Stability"Stable" means a medical condition for which:
  1. there has been NO increase in symptoms or development of new symptoms; NO test results showing deterioration,
  2. a Physician has not determined that the condition has become worse,
  3. a Physician has NOT recommended or prescribed a reduction, increase or stoppage in medication dosage or its frequency, or a change in Treatment,
  4. a Physician has NOT recommended or prescribed a new medication,
  5. You have NOT been Hospitalized or required medical consultation (other than a routine examination where NO medical signs or symptoms existed or were found during the exam), and
  6. You are NOT awaiting further investigation, or results thereof, for that medical condition.
 		  
a) Any stomach, bowel, digestive, gastrointestinal disorder for which you have been referred to a GI specialist or specialty clinic or that has required prescription medication or surgery (Exception: GERD, Diverticulosis and routine colonoscopies; see the Key Terms document)Diverticulosis are small bags (diverticulae) that appear on the walls of the colon. Diverticulitis is an inflammation of the diverticulae resulting from an infection. Ulcerated colitis is a chronic inflammatory condition that affects the colon and the rectum. Intestinal bleeding identifies any blood loss through the gastro-intestinal tract (from the mouth to the anus).
 
b) Liver disorder/Spleen/Pancreas/Gallbladder disorder, Gallstones not eliminated. Answer NO to this question if the Gallbladder is removedCirrhosis is an irreversible chronic condition of the liver. It results from prolonged abuse of liver cells (alcoholism, viruses, medication). Hepatitis is used to describe any accute or chronic inflammation of the liver. Severe hepatitis can lead to the destruction of the liver and death. There are several forms of hepatitis identified as A, B, C, D and E. Pancreatitis is an inflamation of the pancreas usually caused by excessive alcohol consumption or by billiary calculi (stones). Pancreatitis comes in 2 variations: acute and chronic. Biliary calculi are made of chrystallised cholesterol. They can obstruct the biliary conducts that carry the bile to the liver and the intestines.
 
c) Kidney disorder, Kidney stones not eliminated, 2 or more bladder or urinary tract infections in the last 12 months or a Catheter implant
 
 
7) DIABETES:
In the last 3 years have you had, have been diagnosed with, treated for or been prescribed or taken medication for : Medications  Stability"Stable" means a medical condition for which:
  1. there has been NO increase in symptoms or development of new symptoms; NO test results showing deterioration,
  2. a Physician has not determined that the condition has become worse,
  3. a Physician has NOT recommended or prescribed a reduction, increase or stoppage in medication dosage or its frequency, or a change in Treatment,
  4. a Physician has NOT recommended or prescribed a new medication,
  5. You have NOT been Hospitalized or required medical consultation (other than a routine examination where NO medical signs or symptoms existed or were found during the exam), and
  6. You are NOT awaiting further investigation, or results thereof, for that medical condition.
 		  
a) Diabetes prescribed insulinIf insulin and oral medications are taken, both conditions (Diabetes with insulin and Diabetes with medication) have to be checked.
 
b) Diabetes prescribed medication (not insulin)If insulin and other prescribed medications are taken, both conditions (Diabetes with insulin and Diabetes with medication) have to be checked.
 
c) Diabetes without medication or impaired glucose toleranceThere is no surcharge for this condition.
 
 
8) CANCER:
Have you ever been diagnosed with, treated for or been prescribed or taken medication for : Medications  Stability"Stable" means a medical condition for which:
  1. there has been NO increase in symptoms or development of new symptoms; NO test results showing deterioration,
  2. a Physician has not determined that the condition has become worse,
  3. a Physician has NOT recommended or prescribed a reduction, increase or stoppage in medication dosage or its frequency, or a change in Treatment,
  4. a Physician has NOT recommended or prescribed a new medication,
  5. You have NOT been Hospitalized or required medical consultation (other than a routine examination where NO medical signs or symptoms existed or were found during the exam), and
  6. You are NOT awaiting further investigation, or results thereof, for that medical condition.
 		  
a) Leukemia or Lymphoma or Multiple Myeloma (cannot be covered)
 
b) Have you had any other form of Cancer not including breast cancer treated with hormone therapy only and not including basal cell or squamous cell skin cancerIf there is a removal of any portion of the lung you must check other lung condition.
 
c) In the 6 months prior to the effective date have you had surgery, chemotherapy or radiation therapy for cancer or malignant tumour(s) (excluding basal cell or squamous cell skin cancer or breast cancer treated only with hormone therapy)
N/A  N/A   
 
9) OTHER RISK FACTORS:
In the last 3 years have you had, have been diagnosed with, treated for or been prescribed or taken medication for : Medications  Stability"Stable" means a medical condition for which:
  1. there has been NO increase in symptoms or development of new symptoms; NO test results showing deterioration,
  2. a Physician has not determined that the condition has become worse,
  3. a Physician has NOT recommended or prescribed a reduction, increase or stoppage in medication dosage or its frequency, or a change in Treatment,
  4. a Physician has NOT recommended or prescribed a new medication,
  5. You have NOT been Hospitalized or required medical consultation (other than a routine examination where NO medical signs or symptoms existed or were found during the exam), and
  6. You are NOT awaiting further investigation, or results thereof, for that medical condition.
 		  
a) In the 24 months prior to the effective date have you smoked or used tobacco products
N/A  N/A   
b) In the 6 months prior to the effective date have you received advice/treatment for a medical emergency in a hospital emergency room two or more times
N/A  N/A   
c) In the 6 months prior to the effective date have you had two or more falls that were reported to a physician
N/A  N/A   
d) In the 12 months prior to the effective date have you been referred to a specialist or specialty clinic or required treatment or prescription medication or surgery for any other medical or physical disorder or condition not referred to above
 
Notes
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