Health insurance covers up to $2000000. Please read the policy before filling out the application.This product is underwritten by Empire Life Insurance Company
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| What is person insured's birth date?
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For Family applications, record birth date of eldest family member. |
STEP 1: TRAVEL AND TRIP INFORMATION
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| Effective Date of the travel insurance contract (if issued) | | Note: Inform person insured that if the application is approved, they must notify their broker immediately if, prior to the effective date,
there is a material change to any of the information recorded in the application. Failure to do so may void the insurance contract and no benefits will be paid. |
| Termination Date of the travel insurance contract (if issued) | |
OR Duration of coverage under the travel insurance contract (if issued)
(if completed, the Duration of Coverage field will determine the Termination Date) | days for Multi-trip annual, combo or single trip |
| Add-ons (Optional): |
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Purchasing a top-up to your existing insurance coverage?To top-up or extend coverage of an annual plan, or to purchase coverage after the departure.- Click Yes and enter the Departure Date (i.e., the date you left or intend to leave Canada,)
- Enter the Effective Date for the desired extension,
- Enter the Termination Date or the Duration of the coverage you wish to purchase.
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| If it is a Top-up, what is the Departure date from Canada? Enter the date you left or intend to leave Canada; it must preceed the the Effective date of this policy. |
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| Coverage Details: |
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| Who is the coverage for? |
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Note: Family denotes oldest adult plus dependants. (All must be eligible.) |
| Are you a visitor to Canada not covered by GHIP? |
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| Do you require coverage in the USA or Mexico? (If "No", save 15%) |
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Do you have a history of medical conditions Circulatory, Vascular or Blood disorders;
Heart or Cardiovascular;
Stroke, Cerebrovascular or Neurological;
Respiratory or Lung;
Diabetes ? (If "No", save 15%) |
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| Allowances (up to maximum 5%): |
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| Early bird savings? (available May 1 - Nov 30)
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STEP 2 : PERSONAL INFORMATION AND PRIVACY NOTICE |
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| Brokers must read the full privacy notice: Personal Information and Privacy Notice
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| Brokers should then read the following consent wording to the client: Consent |
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STEP 3 : ELIGIBILITY: |
Eligibility
To be eligible for coverage under the contract, as of the Application Date, a Person Insured must be physically present in Canada.
This requirement does not apply if You are applying for a Single Trip Coverage as a Top-Up coverage for another travel insurance contract.
To be eligible for coverage under the contract, as of the Effective Date, a Person Insured must:
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- be a Canadian citizen or permanent resident; ot
- be a visitor to Canada;
- be at least 15 days old and less than 95 years of age;
- be the Policyowner, unless the sole Person Insured is under the age of 18 (if in Quebec) or age 16 (all other Canadian provinces or territories), in which case the Policyowner must be the Person Insured’s parent or legal guardian;
- if not the Policyowner, be a Spouse or Dependent of the Policyowner; and
- be insurable in accordance with Our then-current underwriting rules.
A Person Insured is not eligible for coverage under the contract if, as of the Effective Date, any of the following applies to a Person Insured, even if disclosed on the Application:
- They are experiencing new or undiagnosed signs or symptoms of a Sickness for which they reasonably expect may require Treatment while the contract is in force, or otherwise have a reasonably foreseeable need for Treatment while the contract is in force;
- In the 12 months prior to the Effective Date, they have:
- Received a diagnosis of Stage 3 or Stage 4 cancer, had cancer that has metastasized or received Treatment for pancreatic cancer or liver cancer;
- Received a Terminal Prognosis or Amyotrophic Lateral Sclerosis (ALS, Lou Gehrig's disease);
- Been prescribed home oxygen (including an oxygen concentrator) or prednisone for a Lung Condition or Heart Condition;
- Had Pulmonary Fibrosis, Cystic Fibrosis, or Interstitial lung disease;
- Been diagnosed with or received Treatment for Stage IV or Stage V Kidney disease, kidney disease requiring dialysis, or Cirrhosis of the liver;
- Used nitroglycerine in any form (spray, patch, or pill) for a Heart Condition for the relief of angina or chest pain or had Cardiomyopathy with a Grade IV ventricle or a ventricular ejection fraction of 40% or less;
- Had a dilation of the aorta or an aneurysm that has not been surgically repaired;
- Been a resident in a long-term care facility or 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);
- Been advised by any Physician that traveling on Your trip would be medically unsafe or that You should not travel on Your trip;
- In the 3 years prior to the Effective Date, they have received Treatment for aplastic anemia, hemolytic anemia, sickle cell anemia, or anemia requiring blood transfusions or bone marrow transplants, or have received Treatment in a Hospital for anemia through iron supplements;
- they have received Treatment for or taken Medication for Congestive Heart Failure (CHF) in the past 5 years; or
- they have undergone a bone marrow transplant, stem cell transplant or an organ transplant (except for a cornea transplant);
DECLARATION OF APPLICANT/PERSON INSURED
- I have read, or the broker has read to me, the Eligibility Requirements above and I understand them; and
- I declare that, based on such requirements, each person insured named on this application is eligible for the travel insurance being applied for and that I am authorized to make such declaration on behalf of each person insured named in this application.
I acknowledge and agree that:
- Approval of this application will be based on the above declaration that each proposed person insured is eligible for the travel insurance being applied for is true and the answers and statements given in the application are true and complete; and
- In the event such declaration or any answers or statements recorded on the application contain any misrepresentation or non-disclosure of a material fact, the insurer may void the insurance contract, no benefits will be paid, and premiums may not be refunded, in cases of fraud.
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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