Easy Links Financial Inc.

For Super Visa, Visitors and Immigrants to Canada - HMC Visitor to Canada Association Plan with pre-ex

Health insurance covers up to $200000. 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

Coverage Details:

Application Type? A monthly billing option is only available for Super Visa, Visitor (365 days minimum).
For shorter trips, select Visitor, Immigrant, Returning Canadian.

Super Visa, Visitor (365 days minimum)
Visitor, Immigrant, Returning Canadian

Note: Super Visa requires a single application for each party.

Health Coverage? (Choose the desired limit)

Do you want Accidental Death coverage? (optional)

starting from $33.75 to $91.13 depending on age. Not available for ages 80 and over.
Note: The Accidental Death coverage is available for the policyowner as primary person insured, and if applicable, any named spouse or dependent(s).

Allowances (up to maximum 5%):

Did person insured purchase HMC travel insurance through Ingle or TruStone last year?

Yes No

Will person insured's Travelling Companion also purchase HMC travel insurance through us?

Yes No

Companion's name:

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

I confirm that I understand and agree to these statements, and I consent to the collection,
use and disclosure of Personal Information as described above and in the Privacy Notice.
If no, do not check the box and do proceed with this application.

STEP 3 : ELIGIBILITY:

Eligibility

To be eligible for coverage under the contract, as of the Effective Date, a Person Insured must:

not be eligible for benefits under a Government Health Insurance Plan;
1. be a visitor to Canada; or
2. be a Canadian citizen or permanent resident returning to reside in Canada;
be at least 15 days old and less than 90 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 travelling or planning to travel to Canada against the advice of a Physician;
They have received a Terminal Prognosis;
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 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 had a bone marrow transplant, stem cell transplant or an organ transplant (but excluding cornea transplants);
In the 6 months prior to the Effective Date, they have been Hospitalized for a Sickness;
They are residing in a nursing home, rest home, convalescent home, rehabilitation centre or home for the aged;
Except as required by minors due to their age, they require assistance with any activities of daily living (i.e., bathing, eating, using a toilet, taking medication(s) or getting into or out of a chair or bed); or
In the 12 months prior to the Effective Date, they have:
1. been prescribed home oxygen (including an oxygen concentrator) or prednisone for a lung condition or heart condition;
2. had pulmonary fibrosis or cystic fibrosis;
3. used nitroglycerine in any form (spray, patch, or pill) for a heart condition for the relief of angina or chest pain, or had heart condition with an ejection fraction of less than 40%; or
4. had any aneurysm that is not surgically repaired.

If the Company determines that a Person Insured was not eligible on the Effective Date, the contract is null and void and is deemed to have never taken effect, no benefits will be payable and premiums may not be refunded in cases of fraud.

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.

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

1) Have you had CIRCULATORY, VASCULAR OR BLOOD DISORDERS in the last 5 years?:

			Medications	Stable and Controlled for"Stable and Controlled" means that within the stability period prior to the application date: there is no new treatment; and there has been no change in treatment or change in treatment frequency or type; and here have been no new signs or symptoms or new diagnosis; and there have been no test results showing deterioration; and there has been no hospitalization; and there has been no referral to a specialist (made or recommended) and you are not waiting surgery or the results of further investigations performed by any medical professional.
a) High Blood Pressure (Hypertension) or Low Blood Pressure (Hypotension)	Yes No
b) Peripheral vascular disease (PVD), peripheral artery disease (PAD), blood disorder, blood clot(s) or anemia	Yes No

2) Have you ever had symptoms or diagnosis for HEART OR CARDIOVASCULAR conditions?:
			Medications	Stable and Controlled for"Stable and Controlled" means that within the stability period prior to the application date: there is no new treatment; and there has been no change in treatment or change in treatment frequency or type; and here have been no new signs or symptoms or new diagnosis; and there have been no test results showing deterioration; and there has been no hospitalization; and there has been no referral to a specialist (made or recommended) and you are not waiting surgery or the results of further investigations performed by any medical professional.
a) Cardiomyopathy, Congestive heart failure or water on the lungs or the use of Lasix or Furosemide	Yes No
b) Any other heart or cardiovascular condition, heart attack, surgery, angioplasty, stent, by-pass, pacemaker, irregular rhythm, valve disorder, coronary artery disease or chest pain investigated by a doctor	Yes No

3) Have you ever had symptoms or diagnosis for STROKE, CEREBROVASCULAR OR NEUROLOGICAL conditions?:
			Medications	Stable and Controlled for"Stable and Controlled" means that within the stability period prior to the application date: there is no new treatment; and there has been no change in treatment or change in treatment frequency or type; and here have been no new signs or symptoms or new diagnosis; and there have been no test results showing deterioration; and there has been no hospitalization; and there has been no referral to a specialist (made or recommended) and you are not waiting surgery or the results of further investigations performed by any medical professional.
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.	Yes No
b) Other Cerebrovascular or Neurological conditions or disorders	Yes No

4) Have you had RESPIRATORY OR LUNG conditions in the last 5 years?:
			Medications	Stable and Controlled for"Stable and Controlled" means that within the stability period prior to the application date: there is no new treatment; and there has been no change in treatment or change in treatment frequency or type; and here have been no new signs or symptoms or new diagnosis; and there have been no test results showing deterioration; and there has been no hospitalization; and there has been no referral to a specialist (made or recommended) and you are not waiting surgery or the results of further investigations performed by any medical professional.
a) Any chronic respiratory condition, lung disorder or lung surgery. (not including Asthma or minor ailments)	Yes No

5) Have you had KIDNEY, GASTRO-INTESTINAL, DIGESTIVE OR LIVER conditions in the last 5 years?:
			Medications	Stable and Controlled for"Stable and Controlled" means that within the stability period prior to the application date: there is no new treatment; and there has been no change in treatment or change in treatment frequency or type; and here have been no new signs or symptoms or new diagnosis; and there have been no test results showing deterioration; and there has been no hospitalization; and there has been no referral to a specialist (made or recommended) and you are not waiting surgery or the results of further investigations performed by any medical professional.
a) Chronic Kidney Disease, Chronic Renal Failure, Pancreatitis, Hepatitis or Cirrhosis of the liver	Yes No
b) Other gastro-intestinal/liver/kidney conditions	Yes No

6) Have you had DIABETES in the last 5 years?:
			Medications	Stable and Controlled for"Stable and Controlled" means that within the stability period prior to the application date: there is no new treatment; and there has been no change in treatment or change in treatment frequency or type; and here have been no new signs or symptoms or new diagnosis; and there have been no test results showing deterioration; and there has been no hospitalization; and there has been no referral to a specialist (made or recommended) and you are not waiting surgery or the results of further investigations performed by any medical professional.
a) Diabetes prescribed insulinIf insulin and oral medications are taken, both conditions (Diabetes with insulin and Diabetes with medication) have to be checked.	Yes No
b) Diabetes prescribed medication (not insulin)If insulin and oral medications are taken, both conditions (Diabetes with insulin and Diabetes with medication) have to be checked.	Yes No
c) Diabetes without medication or impaired glucose toleranceThere is no surcharge for this condition.	Yes No

7) Have you ever had CANCER?:
			Medications	Stable and Controlled for"Stable and Controlled" means that within the stability period prior to the application date: there is no new treatment; and there has been no change in treatment or change in treatment frequency or type; and here have been no new signs or symptoms or new diagnosis; and there have been no test results showing deterioration; and there has been no hospitalization; and there has been no referral to a specialist (made or recommended) and you are not waiting surgery or the results of further investigations performed by any medical professional.
a) Leukemia or Lymphoma or Multiple Myeloma (cannot be covered)	Yes No
b) Have you had any other form of Cancer and not including basal cell or squamous cell skin cancer	Yes No
c) In the 6 months prior to the effective date have you had chemotherapy or radiation therapy for cancer or malignant tumour(s)	Yes No

8) Do you have any OTHER RISK FACTORS you would like to be covered?:
			Medications	Stable and Controlled for"Stable and Controlled" means that within the stability period prior to the application date: there is no new treatment; and there has been no change in treatment or change in treatment frequency or type; and here have been no new signs or symptoms or new diagnosis; and there have been no test results showing deterioration; and there has been no hospitalization; and there has been no referral to a specialist (made or recommended) and you are not waiting surgery or the results of further investigations performed by any medical professional.
a) Have you had symptoms, 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	Yes No
b) Syncope or dizzy spells or fainting that was reported to a doctor or hospital	Yes No
c) In the 6 months prior to the effective date have you had two or more falls that were reported to a physician	Yes No	N/A		N/A
d) In the 6 months prior to the effective date have you received advice/treatment for a medical emergency in a hospital for any of the conditions listed in this medical questionnaire	Yes No	N/A		N/A

Notes

Please enter any additional, pertinent information and any other information relating to your health here:

(500 characters)

Key Terms Used in this Application and Policy

Answers on the application: Each condition requires the applicant to answer either "Yes" or "No" depending on whether the applicant has had such a condition, including symptoms or investigation or consultation concerning a certain condition. If the condition has been specifically ruled out and no further follow-up action has been or needs to be taken then the applicant can answer "No" to the condition. If the applicant answers "Yes" to any condition, the applicant must state how many medications they are taking for that condition and for how long the condition has been stable. This information will help to determine if the client can be covered for their condition. If a client has too many medications for major conditions they may be excluded from coverage.

Auto-immune disorder includes acquired immune deficiency syndrome (AIDS) or human immunodeficiency virus (HIV), Grave's disease, Lou Gehrig's disease, multiple sclerosis, myasthenia gravis, sarcoidosis any location, scleroderma, systematic lupus erythematosis.

Blood Disorder includes anemia (other than vitamin B-12 deficiency anemia), hemochromatosis, idiopathic thrombocytopenic purpura (ITP), hemophilia, polycythemia vera, Sickle-cell anemia.

Deductible means the amount which the Insured must pay before any remaining covered expenses are reimbursed under this policy. Your deductible is indicated on your confirmation of coverage and applies once per Insured per Policy Period.

Emergency means an unexpected or unforeseeable sickness or injury which requires immediate medical attention or treatment to prevent or alleviate existing danger to life or health, or to relieve acute symptoms, that cannot be delayed until you return to your province.

High-risk activity(ies) includes skiing or snowboarding out of bounds, ski jumping, skydiving, skysurfing, scuba diving (except if certified by internationally recognized and accepted program such as NAUI or PADI, or if diving depth does not exceed 30 meters), white water rafting (except grades 1 to 4), street luge, skeleton activity, mountaineering, or participation in any rodeo activity.

Major organ means, heart, kidney, liver or lung.

Medical consultation means any medical services obtained from a licensed medical practitioner for a sickness, injury or medical condition, including but not limited to any or all of: history taking, medical examination, investigative testing, advice or treatment, and during which a diagnosis of the condition need not have been definitively made. This does not include regular medical check-ups where no medical signs or symptoms existed between check-ups or were found during the check-up.

Minor Ailment means any sickness or injury which does not require:

the use of medication for a period greater than 15 days;
more than one follow-up visit to a physician;
hospitalization, surgical intervention, or referral to a specialist; and
which ends at least thirty (30) days prior to your effective date.

A chronic condition or any complication thereof is not considered a minor ailment; it is a pre-existing condition.

Other Cerebrovascular or Neurological conditions or disorders: includes Parkinson's disease, epilepsy, cerebral palsy, multiple sclerosis, brain injury or brain tumor, seizure disorder, Lou Gehrig's disease (ALS), Creutzfeldt-Jakob disease, Cushing's syndrome, Guillain-Barré syndrome (GBS), trigeminal neuralgia (TN or TGN).

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

Recurrence means the appearance of signs or symptoms caused by or related to a medical condition which was previously diagnosed by a physician or for which treatment was previously received.

Signs or symptoms means any evidence of disease experienced by you or recognized through observation.

Stable as indicated on your medical statement summary (if applicable), means that during the specified period:

there has been no new treatment; and
there has been no change in treatment or change in treatment frequency or type; and
there have been no signs or symptoms or new diagnosis; and
there have been no test results showing deterioration; and
there has been no hospitalization; and
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:

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);
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;
a minor ailment.

Stomach, bowel, digestive, gastrointestinal disorder includes any condition along the gastrointestinal tract (from the mouth to the anus) and can include (among others) esophagus disorder, stomach disorder, ulcer, hernia, irritable bowel syndrome (IBS), inflammatory bowel disease, gastrointestinal bleeds, gastritis, Chrohn's disease, Celiac disease, diverticulitis, ulcerative colitis, colitis, bowel obstruction, bowel resection or ostomy.

Exceptions: The following conditions are not subject to any surcharge but must be noted in the note section of the medical questionnaire:

Gastroesophageal reflux disease (GERD); or
removal of polyps during a routine colonoscopy where no signs or symptoms were present; or
diverticulosis.

Terminal applies to a medical condition for which a physician gave a prognosis of eventual death or for which palliative care was received prior to the effective date.

Treatment means a medical, therapeutic or diagnostic procedure prescribed, performed or recommended by a physician including, but not limited to, prescribed medication, investigative testing or surgery.

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