Easy Links Financial Inc.

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For Travel Outside of Canada - HMC Value Travel with pre-ex

Health insurance covers up to $2000000. Please read the policy before filling out the application.

This product is underwritten by Empire Life Insurance Company
What is person insured's birth date?   

STEP 1: TRAVEL AND TRIP INFORMATION
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):    
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.
  1. Click Yes and enter the Departure Date (i.e., the date you left or intend to leave Canada,)
  2. Enter the Effective Date for the desired extension,
  3. Enter the Termination Date or the Duration of the coverage you wish to purchase.
 
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.  
Coverage Details:    
Are you a visitor to Canada not covered by GHIP?
 
Do you require coverage in the USA or Mexico? (If "No", save 15%)
 
Allowances (up to maximum 5%):    
     

STEP 2 : PERSONAL INFORMATION AND PRIVACY NOTICE

 
Brokers must read the full privacy notice: Personal Information and Privacy Notice
Brokers should then read the following consent wording to the client: Consent
 

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:
    1. be a Canadian citizen or permanent resident; ot
    2. be a visitor to Canada;
  2. be at least 15 days old and less than 95 years of age;
  3. 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;
  4. if not the Policyowner, be a Spouse or Dependent of the Policyowner; and
  5. 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:
    1. Received a diagnosis of Stage 3 or Stage 4 cancer, had cancer that has metastasized or received Treatment for pancreatic cancer or liver cancer;
    2. Received a Terminal Prognosis or Amyotrophic Lateral Sclerosis (ALS, Lou Gehrig's disease);
    3. Been prescribed home oxygen (including an oxygen concentrator) or prednisone for a Lung Condition or 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 had Cardiomyopathy with a Grade IV ventricle or a ventricular ejection fraction of 40% or less;
    7. Had a dilation of the aorta or an aneurysm that has not been surgically repaired;
    8. 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);
    9. 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
    1. I have read, or the broker has read to me, the Eligibility Requirements above and I understand them; and
    2. 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:
    1. 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
    2. 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.

    STEP 4 : MEDICAL QUESTIONNAIRE - You MUST answer all questions, as your answers form the medical statement and become part of the policy.

     
    1) CIRCULATORY, VASCULAR OR BLOOD DISORDERS:
    In the last 5 years have you had, have been diagnosed with, treated for or been prescribed or taken medication for : Current Medications  Condition has been Stable for"Stable" means that during the specified period:
    1. there has been no new treatment; and
    2. there has been no change in treatment or change in treatment frequency or type; and
    3. there have been no signs or symptoms or new diagnosis; and
    4. there has been no hospitalization; and
    5. there has been no referral to a specialist (made or recommended) and you are not awaiting the results of further investigations performed by any medical professional.
    Exceptions:
    1. the routine adjustment of Coumadin, warfarin, or insulin (as long as the medication is not first prescribed or stopped during the 90 days prior to the effective date);
    2. change from a brand name medication to a generic medication provided the medication was not first prescribed during 90 days prior to the effective date and there is no increase or decrease in dosage;
    3. a minor ailment.
         		  
    a) High Blood Pressure (Hypertension), Low Blood Pressure (Hypotension) or Edema (Oedema)
    		 
    b) Peripheral Vascular Disease (PVD), peripheral artery disease (PAD) or repaired aneurysm (excluding varicose veins and venous stasis)
    		 
    c) Carotid stenosis of 50% or more not repaired by surgery
    		 
    d) Anemia other than Aplastic anemia, Hemolytic anemia, Sickle cell anemia or anemia requiring blood transfusions or bone marrow transplants in the past 3 years, blood disorder or blood clot(s)
    		 
     
    2) HEART OR CARDIOVASCULAR:
    Have you ever been diagnosed with, treated for or been prescribed or taken medication for : Current Medications  Condition has been Stable for"Stable" means that during the specified period:
    1. there has been no new treatment; and
    2. there has been no change in treatment or change in treatment frequency or type; and
    3. there have been no signs or symptoms or new diagnosis; and
    4. there has been no hospitalization; and
    5. there has been no referral to a specialist (made or recommended) and you are not awaiting the results of further investigations performed by any medical professional.
    Exceptions:
    1. the routine adjustment of Coumadin, warfarin, or insulin (as long as the medication is not first prescribed or stopped during the 90 days prior to the effective date);
    2. change from a brand name medication to a generic medication provided the medication was not first prescribed during 90 days prior to the effective date and there is no increase or decrease in dosage;
    3. a minor ailment.
         		  
    a) Disorders of the heart rhythm or conduction including atrial fibrillation, arrhythmia and bundle branch block or a pacemaker implant
    		 
    b) Heart attack (Myocardial infarction), Arteriosclerosis, Chest pain, Angina, or Coronary artery disease (CAD) (answer NO if a bypass, angioplasty or stent was inserted after your last heart attack)
    		 
    c) Surgery for Heart by-pass, Angioplasty or Stent less than 16 years ago
    		 
    d) Surgery for Heart by-pass, Angioplasty or Stent 16 or more years ago
    		 
    e) Valvular heart disorder or last surgery less than 8 years ago
    		 
    f) Valvular heart surgery or an implanted cardioverter-defibrillator (ICD) 8 or more years ago
    		 
    g) Any other heart/cardiovascular conditions not listed above (describe in a note)
    		 
     
    3) STROKE, CEREBROVASCULAR OR NEUROLOGICAL:
    Have you ever been diagnosed with, treated for or been prescribed or taken medication for : Current Medications  Condition has been Stable for"Stable" means that during the specified period:
    1. there has been no new treatment; and
    2. there has been no change in treatment or change in treatment frequency or type; and
    3. there have been no signs or symptoms or new diagnosis; and
    4. there has been no hospitalization; and
    5. there has been no referral to a specialist (made or recommended) and you are not awaiting the results of further investigations performed by any medical professional.
    Exceptions:
    1. the routine adjustment of Coumadin, warfarin, or insulin (as long as the medication is not first prescribed or stopped during the 90 days prior to the effective date);
    2. change from a brand name medication to a generic medication provided the medication was not first prescribed during 90 days prior to the effective date and there is no increase or decrease in dosage;
    3. a minor ailment.
         		  
    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) Parkinson's disease, epilepsy, muscular dystrophy, cerebral palsy, multiple sclerosis, myasthenia gravis or other neurological conditions
    		 
     
    4) RESPIRATORY OR LUNG:
    In the last 5 years have you had, have been diagnosed with, treated for or been prescribed or taken medication for : Current Medications  Condition has been Stable for"Stable" means that during the specified period:
    1. there has been no new treatment; and
    2. there has been no change in treatment or change in treatment frequency or type; and
    3. there have been no signs or symptoms or new diagnosis; and
    4. there has been no hospitalization; and
    5. there has been no referral to a specialist (made or recommended) and you are not awaiting the results of further investigations performed by any medical professional.
    Exceptions:
    1. the routine adjustment of Coumadin, warfarin, or insulin (as long as the medication is not first prescribed or stopped during the 90 days prior to the effective date);
    2. change from a brand name medication to a generic medication provided the medication was not first prescribed during 90 days prior to the effective date and there is no increase or decrease in dosage;
    3. a minor ailment.
         		  
    a) Chronic Obstructive Pulmonary Disease (COPD), chronic bronchitis, emphysema or asbestosis.
    		 
    b) 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)
    		 
     
    5) KIDNEY, GASTRO-INTESTINAL, DIGESTIVE OR LIVER:
    In the last 5 years have you had, have been diagnosed with, treated for or been prescribed or taken medication for : Current Medications  Condition has been Stable for"Stable" means that during the specified period:
    1. there has been no new treatment; and
    2. there has been no change in treatment or change in treatment frequency or type; and
    3. there have been no signs or symptoms or new diagnosis; and
    4. there has been no hospitalization; and
    5. there has been no referral to a specialist (made or recommended) and you are not awaiting the results of further investigations performed by any medical professional.
    Exceptions:
    1. the routine adjustment of Coumadin, warfarin, or insulin (as long as the medication is not first prescribed or stopped during the 90 days prior to the effective date);
    2. change from a brand name medication to a generic medication provided the medication was not first prescribed during 90 days prior to the effective date and there is no increase or decrease in dosage;
    3. a minor ailment.
         		  
    a) Bowel condition including ulcerative colitis, Crohn's disease, diverticulitis, bowel obstruction, bowel surgery, chronic constipation, Irritable Bowel Syndrome (IBS) or gastrointestinal bleed
    		 
    b) Hepatitis C
    		 
    c) Kidney disorder, pancreatitis, kidney stones not eliminated, gall stones not eliminated (ignore gall stones if the gall bladder was removed), 2 or more bladder or urinary tract infections in the last 12 months.
    		 
     
    6) DIABETES:
    In the last 5 years have you had, have been diagnosed with, treated for or been prescribed or taken medication for : Current Medications  Condition has been Stable for"Stable" means that during the specified period:
    1. there has been no new treatment; and
    2. there has been no change in treatment or change in treatment frequency or type; and
    3. there have been no signs or symptoms or new diagnosis; and
    4. there has been no hospitalization; and
    5. there has been no referral to a specialist (made or recommended) and you are not awaiting the results of further investigations performed by any medical professional.
    Exceptions:
    1. the routine adjustment of Coumadin, warfarin, or insulin (as long as the medication is not first prescribed or stopped during the 90 days prior to the effective date);
    2. change from a brand name medication to a generic medication provided the medication was not first prescribed during 90 days prior to the effective date and there is no increase or decrease in dosage;
    3. a minor ailment.
         		  
    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.
    		 
     
    7) CANCER:
    Have you ever been diagnosed with, treated for or been prescribed or taken medication for : Current Medications  Condition has been Stable for"Stable" means that during the specified period:
    1. there has been no new treatment; and
    2. there has been no change in treatment or change in treatment frequency or type; and
    3. there have been no signs or symptoms or new diagnosis; and
    4. there has been no hospitalization; and
    5. there has been no referral to a specialist (made or recommended) and you are not awaiting the results of further investigations performed by any medical professional.
    Exceptions:
    1. the routine adjustment of Coumadin, warfarin, or insulin (as long as the medication is not first prescribed or stopped during the 90 days prior to the effective date);
    2. change from a brand name medication to a generic medication provided the medication was not first prescribed during 90 days prior to the effective date and there is no increase or decrease in dosage;
    3. a minor ailment.
         		  
    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)
    		     
     
    8) OTHER RISK FACTORS:
    Have you ever been diagnosed with, treated for or been prescribed or taken medication for : Current Medications  Condition has been Stable for"Stable" means that during the specified period:
    1. there has been no new treatment; and
    2. there has been no change in treatment or change in treatment frequency or type; and
    3. there have been no signs or symptoms or new diagnosis; and
    4. there has been no hospitalization; and
    5. there has been no referral to a specialist (made or recommended) and you are not awaiting the results of further investigations performed by any medical professional.
    Exceptions:
    1. the routine adjustment of Coumadin, warfarin, or insulin (as long as the medication is not first prescribed or stopped during the 90 days prior to the effective date);
    2. change from a brand name medication to a generic medication provided the medication was not first prescribed during 90 days prior to the effective date and there is no increase or decrease in dosage;
    3. a minor ailment.
         		  
    a) In the 24 months prior to the effective date have you smoked or used tobacco products
    		     
    b) In the 12 months prior to the effective date have been prescribed or taken Lasix or Furosemide for any reason
    		     
    c) In the 6 months prior to the effective date have you received advice/treatment in a hospital for any of the conditions mentioned above in sections 2 through 8, or have you received advice/treatment in a hospital two or more times for any other medical condition (answer NO if the treatment was removal of the gall bladder or removal of kidney stones)
    		     
    d) In the 6 months prior to the effective date have you had two or more falls that were reported to a physician
    		     
    Notes
    Please enter any additional, pertinent information and any other information relating to your health here: (500 characters)

    Key Terms and Definitions Used in this Application

    bowel condition: includes ulcerative colitis, Crohn’s disease, diverticulitis, bowel obstruction, bowel surgery, chronic constipation or Irritable Bowel Syndrome (IBS).

    chronic: means a medical condition that continues, persists, is episodic or recurrent over an extended period of time. This condition is usually long lasting and does not easily or quickly resolve itself.

    complete medical examination: means that you have visited a licensed physician or licensed practitioner where your medical history was updated, any symptoms were diagnosed and any test(s) requested or proposed were completed and you are aware of the results of such test(s).

    emergency or emergencies: means an unforeseen mental or emotional disorder that requires admission to a hospital, a sickness or an injury which occurs during your trip and requires immediate treatment to prevent or alleviate existing danger to life or health. An emergency no longer exists when the medical evidence indicates that you are no longer receiving emergent medical care and are able to be discharged from the medical facility.

    heart condition: includes:

    1. abnormal heart rhythm, arrhythmia, atrial fibrillation or irregular heartbeat;
    2. pacemaker or defibrillator insertion or replacement;
    3. heart attack (myocardial infarction);
    4. heart transplant;
    5. coronary artery disease or angina;
    6. coronary angioplasty or stent insertion;
    7. coronary artery bypass;
    8. heart valve disease, regurgitation or stenosis (mild, moderate or severe);
    9. heart murmur;
    10. pericarditis or
    11. cardiomyopathy and
    12. any other heart disease or disorder.

    liver condition: includes Hepatitis C or Cirrhosis. An individual with Hepatitis C may purchase this policy but an individual with Cirrhosis is not eligible to purchase this policy.

    lung condition: includes Chronic Obstructive Pulmonary Disease (COPD), chronic bronchitis, emphysema, pulmonary fibrosis, asbestosis, interstitial lung disease, lung surgery or chronic asthma. (This does not include seasonal allergies or a minor ailment).

    medication(s): means any physician-prescribed drug (whether filled or not) or remedy used in the treatment of disease and the maintenance of health, including new prescriptions, any renewal(s) or refill, insulin, or nitroglycerine (in any form, with or without a prescription). It does not include other drugs and remedies obtained without a prescription, including aspirin (or equivalent), vitamins, minerals and hormone replacement (or therapy).

    minor ailment: means a non-chronic infection (except for any condition requiring the use of Prednisone or equivalent steroid medication in pill form) which does not require any follow up consultation to any medical provider beyond the initial assessment and includes the use of no more than 2 medications for a maximum of 14 days.

    pre-existing condition: means a medical or physical condition, symptom or complaint, illness or disease, whether diagnosed or not, for which treatment has been received or taken, or which exhibited symptoms, at any time preceding any departure date and includes a medically recognized complication or recurrence of a medical condition but does not include a minor ailment.

    stable or stability: means the medical condition is not worsening and there has been no alteration in any medication (including a new prescription) for the condition or in its usage or in its dosage, a physician has not received any test results indicating a deterioration of your medical condition, you have not been advised by a physician that you should have a surgical procedure, nor has there been any alteration in treatment prescribed or recommended by a physician or received within the pre-existing condition time period you qualify for or have chosen. The following are not considered alterations or changes in medications: the change from a brand named medication to a generic brand medication provided the usage or dosage has not changed; the dosage changes of the regulatory medications insulin or Coumadin, Warfarin, Pradaxa, Pradax or Dabigatran.

    treatment, treat or treated: means a medical, therapeutic or diagnostic procedure prescribed, performed or recommended by a physician or other licensed medical practitioner, including but not limited to prescribed medication, investigative testing or hospitalization, surgery or recommended action that is related to the condition.


    Available Actions:

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