Over55app

APPLICATION
For Ages 55 or Older
Policy Number ___________- 10 -_________________________ PERSONAL INFORMATION
Your personal information is collected for the purpose of providing you with insurance services, claims analysis and payments.
For a copy of the etfs Privacy Policy, please see www.etfsinc.com. For Privacy Information, please see www.rsagroup.ca.
_________________________________________________ First Name ______________________________________ M/F ____________ Day___________ Month__________ Year____________ Street ____________________________________________ City ____________________________________________ Province _________ Postal Code _______________________________________ Telephone ( __________ ) __________________________________________ Name____________________________________________ Telephone ( __________ ) __________________________________________ Destination Address Street ____________________________________________ City ____________________________________________ State ____________ Zip Code _________________________________________ Telephone ( __________ ) __________________________________________ Please refer to the following definitions while completing your Application.
1. “BROKER” means the broker from whom you purchased the policy.
2. “DEPARTURE DATE” means the day you cross the border of your country, province or territory.
3. “EFFECTIVE DATE” means coverage will begin at 0:01 a.m. on the effective date you choose.
4. “EXPIRY DATE” means coverage will terminate at 11:59 p.m. on the expiry date you choose.
5. “METASTATIC CANCER” means a cancer that has spread from its original site to one or more other area(s) of the body.
6. “MINOR AILMENT” means any sickness or injury which does not require the use of medication for a period of 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 30 consecutive days prior to the departure date2of each trip. However, a chronic condition or complications of a chronic condition are not considered a minor ailment.
7. “REGULAR CHECK-UP” means any standard or customary medical examination unrelated to any specific medical condition and which is carried out for
the purposes of screening, health monitoring or preventive care and may include medical tests and investigations.
8. “STABLE” means any medical condition (other than a minor ailment6) for which all the following statements are true:
a. There has been no new diagnosis, treatment or prescribed medicationb. There has been no change in treatment or change in medication, including the amount of medication to be taken, how often it is taken, the type of medication or change in treatment frequency or type. Exceptions: the routine adjustment of Coumadin, Warfarin, oral medication or insulin to controldiabetes (as long as they are not newly prescribed or stopped) and a change from a brand name medication to a generic brand medication (provided thedosage is not modified);.
c. There has been no new symptom, more frequent symptom or more severe symptom;d. There have been no test results showing deterioration;e. There has been no hospitalization or referral to a specialist (made or recommended) and you are not awaiting the results of further investigations for that “TERMINAL ILLNESS” means that you have a medical condition that is cause for a physician to estimate that you have less than 6 months to live or for
which palliative care has been received.
10. “TREATED” means that you have been hospitalized, have been prescribed medication, (including prescribed as needed) have taken or are currently taking
medication or have undergone a medical or surgical procedure. Note that Aspirin/Entrophen is not considered treatment.
ELIGIBILITY
You must meet the following criteria to be eligible for this insurance:
• This Application must be completed prior to the effective date3 and only You can complete and sign this Application. You must not permit anyone else to complete and/or sign the Application on your behalf. Should you need to make a correction to your answers in this Application, please call your broker1 for instructions.
• You must be a Canadian resident and you must be covered under the government health insurance plan in your Canadian province or territory of residence for the
• You must not be travelling against the advice of a physician or have been diagnosed with a terminal illness9 or metastatic cancer5 .
• You must not have a kidney disease requiring dialysis.
• You must not have been prescribed or used home oxygen during the 12 months prior to your departure date2.
• You must not have been diagnosed with AIDS (acquired immune deficiency syndrome) or HIV (Human Immunodeficiency Virus).
• Your insurance coverage is issued on the basis of the answers you have provided on your Application and receipt of full payment. In the event of a claim, the
answers you have provided will be reviewed for accuracy by the Insurer. If they are inaccurate in any way your claim will be denied.
• If your health changes or does not remain stable8 between the date you complete and submit the Application and your departure date2, you must review the Application with your broker1 to re-assess your eligibility for this insurance. If you no longer qualify for the insurance you purchased and you fail to contact yourbroker1, your claim will be denied, your policy will be declared null and void, and the premium you paid will be refunded. This means no benefits will be coveredand you will be responsible for all expenses related to your accident, injury or sickness, including repatriation costs. If you are purchasing a Multi-trip AnnualPlan and your health changes or does not remain stable8 after the date you choose for coverage to begin, your medical condition may not be covered Please complete the Medical Questionnaire on the reverse side before proceeding.
MULTI-TRIP ANNUAL PLAN COVERAGE (AVAILABLE UP TO AGE 79)
1. Effective Date3 Day______ Month _______ Year ______
2. Plan Options
3. Premium:
SINGLE TRIP DAILY PLAN COVERAGE (AVAILABLE AT ANY AGE LEVEL)
Information
2. If you are topping up an existing plan, indicate the number of days that you are covered under this existing insurance plan:
3. Number of days to be covered by top up, from
4. Premium: Daily Rate for total number of days (A) multiplied by the number of days to be covered (C)
Subtotal (Total of Annual plan and Single Trip premium)
TOTAL PREMIUM CALCULATION
Deductible options: See Rate Sheet - Using the applicable % of subtotal, calculate the increase/decrease.
Special discount (if applicable) (A surcharge of $25 applies if you are topping up another carrier’s coverage.) Total Premium (minimum premium $25)
Broker Name (Please Print)
TravelPro Emergency Medical Travel Insurance is underwritten by Royal & Sun Alliance Insurance Company of Canada and isadministered by Expert Travel Financial Security (E.T.F.S.) Inc.
Offered through
TM RSA" and the RSA logo are trademarks owned by RSA Insurance Group plc licensed for use by Royal & Sun Alliance Insurance Company of Canada. Legal Surname _____________________________________________________ First Name ________________________________________________________ MEDICAL QUALIFICATIONS
You must answer NO to each of the following 6 Medical Qualification questions to qualify for this insurance. The answers you provide will, in the event of a claim, be
reviewed for accuracy by Global Excel Management Inc. If they are inaccurate in any way, your claim will be refused and your Policy will be void.
1. Have you ever had a Bone marrow transplant or an organ transplant (excluding corneal transplant)?
2. Have you had a Heart bypass surgery and/or Heart angioplasty more than 10 years prior to your Application date?
(Use the date of the most recent bypass and/or angioplasty.) 3. During the 5 years prior to your Application have you been diagnosed with or treated10 for Congestive heart failure or are you
currently taking Lasix, Furosemide or a water pill (excluding a water pill taken for high blood pressure only)? 4. During the 12 months prior to your Application, have you:
• been diagnosed with or been hospitalized for a new Heart condition, or had an existing Heart condition which required hospitalization • had a Lung condition (including pneumonia) which required hospitalization or treatment with Prednisone (Deltasone or other generic drugs)? 5. During the last 12 months prior to your Application, have you been diagnosed with, or been treated10 for a total of 3 or more of the following
medical conditions: Heart condition (including stent placement, pacemaker and/or defibrillator), Lung condition (including any prescriptionfor puffers/inhalers) excluding a minor ailment6, High blood pressure, Diabetes (treated10 with oral medication or insulin), Stroke (CVA)/mini-stroke (TIA), Peripheral vascular disease (narrowing or blockage of an blood vessel) 6. Do you have an Aneurysm of 3.5 cm or more which remains surgically unrepaired?
If you answered YES TO ANY of the Medical Qualification questions, you are NOT ELIGIBLE to purchase this insurance. Please contact your broker1 to discuss your options.
If you answered NO TO ALL the Medical Qualification questions, you ARE ELIGIBLE to purchase this insurance. Please continue to the Plan Qualification questions.
PLAN QUALIFICATIONS
You must answer all Plan Qualification questions.
QUESTION 1
Have you ever been diagnosed with or treated10 for a Heart condition (including stent, pacemaker and/or defibrillator), a Stroke or Mini-stroke (CVA/TIA),
OR in the 5 years prior to your Application have you smoked cigarettes, OR has it been more than 18 months since your last regular check-up7.
QUESTION 2
During the 2 years prior to your Application, have you been diagnosed with or treated10 for, any of the following medical conditions:
• Chronic bowel disease (such as but not limited to: • Kidney disease (including stones).
• Bowel obstruction or have had bowel surgery• Gall bladder disease (including stones). If your gall bladder has been removed answer No.
QUESTION 3
In the 5 years prior to your Application, have you been diagnosed with or treated10 for any of the following medical conditions:
• Heart condition (including stent placement, pacemaker and/or defibrillator)• Stroke (CVA)/mini-stroke (TIA)• Any Lung condition (including any prescriptions for puffers/inhalers) excluding a minor ailment6• Peripheral vascular disease (blocked or clogged arteries in the leg or neck)• Alzheimer’s disease or dementia• Diabetes (treated10 with oral medication and/or insulin or controlled by diet) or Glucose intolerance (pre-diabetes)?• Cancer (excluding basal or squamous cell skin cancer or breast cancer treated10 only with Tamoxifem, Femara or Arimides)? You must check the box beside the Plan for which you have qualified and read the Pre-Existing Medical Condition Exclusions.
If you answered No to all questions, you qualify for the Platinum rates which do not cover losses or expenses caused directly or indirectly, in whole or in part, by:
1. any sickness, injury or medical condition (other than a minor ailment6) that was not stable8 at any time during the 90 days prior to each departure date2.
2. Your heart condition, if any heart condition was not stable8 at any time during the 90 days prior to each departure date2.
3. Your lung condition, if:
a. any lung condition was not stable8: or
Platinum
b. you have been treated10 with home oxygen or taken oral steroids (e.g. prednisone) for any lung condition, at any time during the
90 days prior to each departure date2.
If you answered Yes to question 1 and No to questions 2 and 3, you qualify for the Gold rates which do not cover losses or expenses caused directly or
indirectly, in whole or in part, by:
1. any sickness, injury or medical condition (other than a minor ailment6) that was not stable8 at any time during the 90 days prior to each departure date2.
2. Your heart condition, if any heart condition was not stable8 at any time during the 90 days prior to each departure date2.
3. Your lung condition, if:
a. any lung condition was not stable8: or
b. you have been treated10 with home oxygen or taken oral steroids (e.g. prednisone) for any lung condition, at any time during the 90 days prior to
If you answered Yes to question 2 and no to question 3, you qualify for the Silver rates which do not cover losses or expenses caused directly or
indirectly, in whole or in part, by:
1. any sickness, injury or medical condition (other than a minor ailment6) that was not stable8 at any time during the 365 days prior to each departure date2.
2. Your heart condition, if any heart condition was not stable8 at any time during the 365 days prior to each departure date2.
3. Your lung condition, if:
a. any lung condition was not stable8: or
b. you have been treated10 with home oxygen or taken oral steroids (e.g. prednisone) for any lung condition, at any time during the 365 days prior
If you answered Yes to question 3, you qualify for the Standard rates which do not cover losses or expenses caused directly or indirectly, in whole or in part, by:
1. any sickness, injury or medical condition (other than a minor ailment6) that was not stable8 at any time during the 365 days prior to each departure date2.
2. Your heart condition, if any heart condition was not stable8 at any time during the 365 days prior to each departure date2.
3. Your lung condition, if:
a. any lung condition was not stable8: or
Standard
b. you have been treated10 with home oxygen or taken oral steroids (e.g. prednisone) for any lung condition, at any time during the 365 days prior
AGREEMENT, UNDERSTANDING AND AUTHORIZATION
You must read and understand the importance of each of the following statements and sign below:
A PRE-EXISTING MEDICAL CONDITION EXCLUSION may apply to medical conditions and/or symptoms that existed prior to my trip. I understand thatany medical condition I have, including those disclosed in the Plan Qualifications will be subject to the Pre-Existing Medical Condition Exclusion of the planI qualify for. I will refer to my policy and to this Application for the full Pre-Existing Medical Condition Exclusion clause.
I personally provided the answers on this Application and I warrant that all information disclosed herein is correct and complete. In the event of a claim Ifully understand that the Insurer will review my prior medical history and these answers and, if any of my answers are incorrect or incomplete, the Insurer willvoid my policy and my claim will be refused, regardless of whether the incorrect or incomplete question is related to the cause of my claim. I understand thatthe answers on my Application are relevant to the risk and constitute the basis of my insurance. Where I was unsure of my medical history as it relates to mymedical questions, I have verified it with my physician.
I understand the necessity of calling Global Excel Management Inc. and obtaining prior approval before seeking medical attention in case of a claim ormedical emergency. The toll free telephone number can be found on my wallet card and in my insurance policy.
I understand that some exclusions may apply and affect my coverage. I will read my insurance policy for additional details.
Medical Authorization in Case of a Claim – I understand that Royal & Sun Alliance Insurance Company of Canada and Global Excel Management Inc. mayinvestigate my claim. By signing this Application, I also hereby direct and authorize any physician, health care practitioner, hospital or other medical carefacility, pharmacy, the Ministry of Health or any other person who has attended and examined me or who has knowledge or records of me or my health, tofurnish to Royal & Sun Alliance Insurance Company of Canada and to Global Excel Management Inc. any or all information with respect to my sickness,injury, medical history, consultations, medicines or treatment and copies of all hospital or medical records for the purpose of investigating my claim.
Signature of Applicant: __________________________________________ TravelPro Emergency Medical Travel Insurance is underwritten by Royal & Sun Alliance Insurance Company of Canada Offered through
and is administered by Expert Travel Financial Security (E.T.F.S.) Inc.
TM "RSA" and the RSA logo are trademarks owned by RSA Insurance Group plc, licensed for use by Royal & Sun Alliance Insurance Company of Canada.

Source: http://www.aistoronto.com/secure/pdf/Over55_2010_ver6.pdf