"*" indicates required fields Step 1 of 5 20% General InformationFirst Name and Last Name:*Date of Birth:* MM slash DD slash YYYY Phone Number:*E-mail:* Address:*City:*Province:*Postal Code:*Vaccine Status*Select Vaccine StatusNo Vaccinations1st Dose2nd Dose3rd Dose4th Dose5th DoseHave you had a positive COVID test?*NoYesIf yes, when?Will there be a travel companion who also requires insurance? If so, enter their name here and have them fill out a separate form:Trip InformationDeparture Date: MM slash DD slash YYYY Return Date: MM slash DD slash YYYY Insurance Option Plans: Single Trip 8 Day Annual 15 Day Annual 30 Day Annual Top Up Indicate Any Additional CoverageDestination*If the USA, Which State? Medical History Section 1CirculatoryHigh Blood Pressure/ Hypertension* Yes No Number of MedicationsNames of medications and date of last changeCholesterol* Yes No Number of MedicationsNames of medications and date of last changeCirculatory Disorder of Artery or Vein (PVD, PAD, DVT)* Yes No Number of MedicationsNames of medications and date of last changeBlood disorder (Anemia and other)/Blood Clots* Yes No Number of MedicationsNames of medications and date of last changeAneurysm of any type and size* Yes No What size of your aneurysm in mm(mm)Date of hospitalization MM slash DD slash YYYY Cardiovascular/HeartArrhythmia/Atrial Fibrillation/ Arteriosclerosis/ Heart Murmur* Yes No Number of MedicationsNames of medications and date of last changeStent/ Pacemaker Implant/ Defibrillator* Yes No Number of MedicationsNames of medications and date of last changeHeart Attack (Myocardial infraction) Chest Pain/Angina* Yes No Number of MedicationsNames of medications and date of last changeCongestive Heart Failure/ Water on the lungs* Yes No Number of MedicationsNames of medications and date of last changeLast By-pass/ Valve surgery/ angioplasty within the last 12 years* Yes No Date of procedure MM slash DD slash YYYY Last By-Pass/ Valve surgery/ angioplasty over 12 years ago* Yes No Date of procedure MM slash DD slash YYYY Have you ever seen a Cardiologist/ Heart Specialist* Yes No When and Why?Other cardiac problems including congenital heart disorders* Yes No Do you take a daily Aspirin 81* Yes No Do you currently have a nitro spray/patch* Yes No Number of MedicationsNames of medications and date of last changeDescription of cardiac problems Medical History Section 2Cerebrovascular/NeurologicalStroke (CVA/TIA) Cerebrovascular accident/ Transient ischemic attack (Mini Stroke)* Yes No Number of MedicationsNames of medications and date of last changeOther Cerebrovascular / Neurological condition or disorders including Syncope, Alzheimer’s, ALS, Parkinson’s, MS, Cerebral Palsy* Yes No Number of MedicationsNames of medications and date of last changeDescription of Cerebrovascular or Neurological conditionsDate of hospitalization MM slash DD slash YYYY Respiratory/LungCOPD/ Emphysema/ Chronic Bronchitis* Yes No Number of MedicationsNames of medications and date of last changeAsthma* Yes No Number of MedicationsNames of medications and date of last changeInhaler/Puffer – single unrepeated prescription for a single episode* Yes No Number of MedicationsNames of medications and date of last changeHave you ever been on Home Oxygen or prednisone* Yes No Number of MedicationsNames of medications and date of last changeOther lung disease or respiratory conditions* Yes No Number of MedicationsNames of medications and date of last changeDescription of other respiratory conditionsDate of hospitalization MM slash DD slash YYYY Medical History Section 3Gastro-Intestinal/Liver/Kidney Disorders & All Internal Disorders Stomach/bowel disorder or obstruction* Yes No Number of MedicationsNames of medications and date of last changeDiverticulitis* Yes No Number of MedicationsNames of medications and date of last changeGastrointestinal Bleeding* Yes No Number of MedicationsNames of medications and date of last changeBleeding or perforated ulcer* Yes No Number of MedicationsNames of medications and date of last changeChronic bowel disorder including Crohn's, Colitis and IBS* Yes No Number of MedicationsNames of medications and date of last changeLiver Disorder/Spleen/Pancreas /Gall Bladder disorder, Gall stones not eliminated* Yes No Number of MedicationsNames of medications and date of last changeCirrhosis of the liver* Yes No Number of MedicationsNames of medications and date of last changeKidney Dialysis/ Renal Insufficiency* Yes No Number of MedicationsNames of medications and date of last changeKidney disorder, Urinary disorder, kidney stones* Yes No Number of MedicationsNames of medications and date of last changeOther Gastrointestinal or Internal condition including ulcer, hernia, acid reflux (GERD), or prostate disorder (Not Cancer)* Yes No Number of MedicationsNames of medications and date of last changeDescription of gastrointestinal/ liver/kidney conditionsOrgan Transplant* Yes No Description for organ transplantDate of hospitalization MM slash DD slash YYYY Cancer Have you ever had cancer* Yes No Terminal or metastatic Terminal Metastatic Neither What type:When:What kind of treatment did you receive Medical History Section 4Diabetes Diabetes with insulin* Yes No Number of MedicationsNames of medications and date of last changeDiabetes with oral medication* Yes No Number of MedicationsNames of medications and date of last changeDiabetes without medication* Yes No Number of MedicationsNames of medications and date of last changeDate of hospitalization MM slash DD slash YYYY Other Risk Factors Have you smoked or used tobacco/cannabis products in the last 2 years?* Yes No Number of MedicationsNames of medications and date of last changeHave you been to the hospital/emergency room in the past 12 months?* Yes No ReasonHave you seen a doctor in the last 12 months?* Yes No Date of Last Medical ChangeNumber of MedicationsNames of medications and date of last changePrescribed medication you have not listed in the above questionnaire and any changes (including dosage changes)Consent* I hereby confirm that the statements and answers given herein are accurate, true and complete. I declare to have read and understood the above questions, regarding my health issues. I understand that if pertinent medical information is omitted and/or falsified, the Insurance Company may reduce my coverage and or render my policy null and void.CommentsCommentsThis field is for validation purposes and should be left unchanged. Δ
