Travel Details

Provide your trip details to get a quote.

What is your Home Country?

What Province is your destination?

Visitor Type

Trip Start Date

Trip End Date

Number of Travellers

Travellers means partners or dependents

Applicant Details

First Name

Last Name

Date of Birth

Date of Birth Month

Date of Birth Day

Date of Birth Year

Relationship to Applicant

Spouse means someone to whom one is legally married, or with whom one has been residing and who is publicly represented as a spouse. a child means your unmarried, dependent son or daughter or your grandchild(ren) under the age of twenty-one (21) or, if a full-time student, under the age of twenty-six (26). Also, an unmarried dependent son or daughter of any age, if mentally or physically disabled.

You are eligible for coverage

Unfortunately {traveler} does not meet eligibility criteria for coverage

Traveller #2 Details

First Name

Last Name

Date of Birth

Date of Birth Month

Date of Birth Day

Date of Birth Year

Relationship to Applicant

You are eligible for coverage

Unfortunately {traveler} does not meet eligibility criteria for coverage

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Agent Details

Brokerage Code

Name of Insurance Brokerage

Check Insurance Eligibility

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All questions are asked from the perspective of application date.

Yes No

Are you travelling contrary to medical advice?

Yes No

Do you require kidney dialysis?

Yes No

In the past 12 months, have you used or been prescribed home oxygen for a lung condition?

Yes No

Have you ever had, or are you awaiting a stem cell, organ, or bone marrow transplant?

Yes No

Do you have a terminal illness for which a physician has estimated you have less than six (6) months to live?

Yes No

Do you have metastatic cancer (cancer that has spread from the original site to another place in your body)?

I have read and understand that if I need to answer “yes” to any of the above eligibility questions, I am not able to purchase this insurance product.

Yes No

In the past 12 months have you been diagnosed with a new heart condition, or had an existing heart condition cause an unexpected visit to a hospital?

Yes No

In the past 12 months have you been diagnosed with a new lung condition, or had an existing lung condition cause an unexpected visit to a hospital?

Yes No

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Yes No

In the past 12 months have you been diagnosed or treated for cancer? (not including basal cell or squamous cell carcinoma)

Yes No

In the past 10 years have you had any cardiovascular surgeries? (including pacemakers)

Yes No

In the past 5 years have you been diagnosed or treated for any narrowed or blocked artery?

Yes No

In the past 5 years have you been diagnosed or treated for any lung condition?

Yes No

In the past 5 years have you been diagnosed or treated for a cerebrovascular accident, stroke or mini-stroke?

Yes No

In the past 3 years have you been diagnosed or treated for diverticulitis or chronic bowel disease?

Yes No

In the past 3 years have you been diagnosed or treated for kidney disease, including stones?

Yes No

In the past 3 years have you been diagnosed or treated for diabetes, other than diabetes managed by diet and exercise?

Yes No

In the past 3 years have you been diagnosed or treated for a pancreatic disease or disorder?

Yes No

In the past 3 years have you been diagnosed or treated for any liver disease?

Yes No

In the past 5 years have you been diagnosed or treated for Alzheimer’s, Parkinson’s or any other form of dementia?

Yes No

In the past 5 years have you been diagnosed or treated for osteoporosis?

Yes No

In the past 12 months have you had 2 or more bladder infections?

Yes No

Are you currently taking medication for high blood pressure?

Yes No

Are you currently taking medication for high cholesterol?

Yes No

Have you been diagnosed with Diabetes but are currently managed by diet and exercise?

Yes No

In the last 12 months, have you smoked tobacco, marijuana or vaped?

Yes No

Are you travelling contrary to medical advice?

Yes No

Are you awaiting investigative testing or treatment of an unresolved condition? Reference to testing, tests, test results, or investigations excludes genetic tests.

Yes No

Do you require kidney dialysis?

Yes No

In the past 12 months, have you used or been prescribed home oxygen for a lung condition?

Yes No

Have you ever had, or are you awaiting a stem cell, organ, or bone marrow transplant?

Yes No

Do you have a terminal illness for which a physician has estimated you have less than six (6) months to live?

Yes No

Do you have metastatic cancer (cancer that has spread from the original site to another place in your body)?

I have read and understand that if I need to answer “yes” to any of the above eligibility questions, I am not able to purchase this insurance product.

Unfortunately {traveler} does not meet eligibility criteria for coverage

Check Insurance Eligibility

For

In lieu of a medical questionnaire, we offer a medical declaration that allows us to create a travel insurance policy that fits your specific needs. We ask that you to declare all your medical conditions that you have been diagnosed with or have been treated in the last three years.

Note: Taking medication for a medical condition is considered being treated for that medical condition.

Please list all your medical conditions accurately and completely. Providing incorrect or incomplete information could result in a denied claim or void policy.

Medical Score

For

Please check your eligibility first

Travel Details

Applicant Details

Traveller #2 Details

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