10 02 apm fca 0706 +op

Declaration
Age 60 or over
Effective September 24, 2007
FOR TRAVEL AGENT USE ONLY
Policy Number:
Date issued (D/M/Y):
Your personal information is collected for the purpose of providing you with insurance services, claims analysis PERSONAL INFORMATION
and payments. Call 1-888-830-6455 for a copy of the etfs Privacy Policy. For Privacy Information,
please see www.royalsunalliance.ca, or call us at 1-800-716-4339.
HOME ADDRESS:
DESTINATION ADDRESS:
Please refer to the following definitions for the words TREATED, STABLE and MINOR AILMENT.
DEFINITIONS
These words appear throughout this medical declaration with the reference notations 1 through 3.
1. Treated means that you have been hospitalized, have been prescribed (including
c. there have been no new symptoms, more frequent symptoms or more severe prescribed as needed), have taken or are currently taking medication or have undergone a medical or surgical procedure.
d. there have been no test results showing deterioration; 2. Stable means any medical condition (other than a minor ailment3) for which all the
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 a. there has been no new diagnosis, treatment or prescribed medication; b. there has been no change in treatment or change in medication, including the 3. Minor ailment means any sickness or injury which does not require the use of
amount of medication to be taken, how often it is taken, the type of medication medication for a period of greater than 15 days, more than one follow up visit to a or change in treatment frequency or type; physician, hospitalization, surgical intervention or referral to a specialist and which Exceptions: the routine adjustment of Coumadin, Warfarin, insulin or oral ends at least 30 consecutive days prior to the departure date of each trip. However, medication to control diabetes (as long as they are not newly prescribed or a chronic condition or complications of a chronic condition are not considered a stopped) and a change from a brand name medication to a generic brand medication (provided that the dosage is not modified).
® The following is a registered trademark of Expert Travel Financial Security (E.T.F.S.) Inc.: Globetrek.
™ The following is a trademark of Expert Travel Financial Security (E.T.F.S.) Inc.: the etfs logo.
™ The Royal & SunAlliance logo is a trademark owned by Royal & Sun Alliance Insurance Group plc, licensed for use by Royal & Sun Alliance Insurance Company of Canada.
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INSTRUCTIONS
This medical declaration must be completed prior to the effective date. ONLY
Note: If you have any doubt about your health as it relates to the eligibility and YOU can complete and sign this application, not your spouse or travel agent.
qualification questions asked, you must consult a physician for advice before STEP 1: Complete the Personal Information section on page 1.
STEP 2: Complete PART A, Eligibility Criteria below.
STEP 4: Check off the plan for which you qualify, in PART D. Be sure to read,
understand and sign the Agreement, Understanding and Authorization section.
STEP 3: Complete PART B - Plan Eligibility and PART C - Plan Qualification by checking
off either YES or NO to each question until your plan eligibility and qualification has been
Should you need to make a correction to your answers pertaining to the medical questions in this medical declaration, please call your travel agent for instructions.
THE ANSWERS YOU PROVIDE WILL, IN THE EVENT OF A CLAIM, BE REVIEWED FOR ACCURACY BY THE INSURER.
IF THEY ARE INACCURATE IN ANY WAY, YOUR CLAIM WILL BE DENIED.
ELIGIBILITY CRITERIA
IMPORTANT : If you must answer YES to any question in PART A, you are NOT ELIGIBLE to purchase this insurance.
This travel insurance is only available to you if you are a Canadian resident or landed immigrant and you answer NO to questions 1 to 4 below.
1. Are you travelling against the advice of a physician or have you been diagnosed with a terminal illness? A “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.
2. Do you have a kidney disease requiring dialysis? 3. During the 12 months prior to your departure date, have you been prescribed or used home oxygen?
4. Have you ever been diagnosed with AIDS (Acquired Immune Deficiency Syndrome)? PLAN ELIGIBILITY
IMPORTANT : If you must answer YES to any questions in PART B, you are NOT ELIGIBLE to purchase this insurance. Other insurance coverage options may exist. Please consult
your travel agent. If you have answered NO to al of the questions, please continue to the Plan Qualification section below.
5. Have you had heart bypass surgery or angioplasty more than 10 years prior to your departure date? (Use the date of your most recent bypass or angioplasty.)
6. Have you ever had an organ transplant (excluding corneal transplant)?
7. Have you been diagnosed with or treated1 for congestive heart failure in the last 5 years or are you currently taking Lasix or furosemide?
8. During the 5 years prior to your departure date, have you been diagnosed with or treated1 for water on your lungs or ankle/leg swelling for which you take Lasix or furosemide
or a water pill (excluding a water pill taken for high blood pressure/hypertension)? 9. During the 12 months prior to your departure date, have you:
a) been diagnosed with or been hospitalized for a new heart condition, or had an existing heart condition which required hospitalization or a change in medication (refer to 2b.
b) had a lung condition (including pneumonia) which required hospitalization or treatment with prednisone (Deltasone or other generics)? c) had a diagnosis of or been treated1 for a total of 3 or more of the following medical conditions?
• Heart condition (including a pacemaker) Lung condition (including any prescription for puffers/inhalers) excluding a minor ailment3 Diabetes (treated with oral medication or insulin) • Peripheral vascular disease or Carotid Artery Stenosis (blocked or clogged arteries in the legs or neck) PLAN QUALIFICATION
SECTION 1 10. During the 5 years prior to your departure date, have you smoked cigarettes?
IMPORTANT !
Please proceed to Section 2.
11. During the 10 years prior to your departure date, have you been diagnosed with or treated1 for a heart condition (including pacemaker)?
12. During the 5 years prior to your departure date, have you been diagnosed with or treated1 for any of the following medical conditions:
a) Lung condition (including any prescription for puffers/inhalers) excluding a minor ailment3? SECTION 2
c) Diabetes (treated with oral medication or insulin)? d) Peripheral vascular disease or Carotid Artery Stenosis (blocked or clogged arteries in the legs or neck)? 13. During the 5 years prior to your departure date, have you been diagnosed with or treated1 for high blood pressure/hypertension
AND high cholesterol/hypercholesterolemia in addition to any condition listed in questions 11 and/or 12?
If you must answer YES to two or more questions in Section 2, you qualify for the Standard Plan. If you must answer YES to only ONE question in
IMPORTANT !
Section 2, you qualify for the Advantage Plan. Please proceed to Part D. If you answer NO to all the questions in Section 2, please proceed to Section 3.
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PLAN QUALIFICATION (continued)
14. During the 12 months prior to your departure date, have you been diagnosed with or treated1 for any of the following medical conditions:
a) Cancer (excluding basal or squamous cell skin cancer or breast cancer treated only with Tamoxifen, Femara or Arimidex)? b) Chronic bowel disease (such as but not limited to: Crohn's disease, ulcerative colitis)? SECTION 3
e) Gallbladder disease (including stones)? If your gallbladder has been removed, answer NO.
f) Liver disease, pancreatitis or kidney disease (including stones)? If you must answer YES to any question in Section 3, you qualify for the Superior Plan. Please proceed to Part D.
IMPORTANT !
If you answer NO to all the questions in Section 3, please proceed to Section 4.
SECTION 4 15. During the 12 months prior to your departure date, have you been diagnosed with or treated1 for high blood pressure/hypertension?
If you must answer YES to any question in Section 1 and/or Section 4, you qualify for the Elite Plan. If you answer NO to all the questions
IMPORTANT !
in Sections 1, 2, 3 and 4 you qualify for the Privilege Plan. Note: If you qualify for the Privilege Plan, you may select either the Privilege Plan or the Elite Plan.
PLEASE INDICATE THE PLAN FOR WHICH YOU QUALIFY AND READ THE PRE-EXISTING MEDICAL CONDITION EXCLUSIONS ON PAGE 4.
PLAN QUALIFICATION TABLE
PRE-EXISTING MEDICAL
YOU QUALIFY FOR:
PRE-EXISTING PERIOD
CONDITION EXCLUSIONS
PRIVILEGE
90 days - stable2
90 days - stable2
SUPERIOR
90 days - stable2
365 days - stable2
ADVANTAGE
(90 days stable2 for high blood pressure/hypertension and
180 days stable2 for cancer)
365 days - stable2
STANDARD
(90 days stable2 for high blood pressure/hypertension and
180 days stable2 for cancer)
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PRE-EXISTING MEDICAL CONDITION EXCLUSIONS
This insurance does not cover losses or expenses caused directly or indirectly, in whole or in part, by: 1. Your medical condition, if at any time in the pre-existing period, your medical condition has not been stable2.
2. Your heart condition, if at any time in the pre-existing period, any heart condition you had, has not been stable2.
3. Your lung condition, if at any time in the pre-existing period:
a) any lung condition you had, has not been stable2; or
b) you have been treated with home oxygen or taken oral steroids (e.g. prednisone) for any lung condition.
IMPORTANT NOTICE:
If your health changes or does not remain stable2 between the date you complete and submit the Medical Declaration and your departure date, you must review the medical
questions in this Medical Declaration with your travel agent to re-assess your eligibility. If you are no longer eligible for the insurance plan you purchased and you fail to contact your travel agent, your claim will be denied, the Insurer will void your policy, and the premium you paid will be refunded. This means no benefits will be covered and you will be responsible for all expenses relating to your sickness or injury, including repatriation costs. If you are purchasing a Multi-Trip Annual Plan and your health changes or does not remain stable2 after the date you choose for coverage to begin, your medical condition may not be covered (see Pre-Existing Medical Condition Exclusions).
You must read and understand the importance of each of the following statements
AGREEMENT, UNDERSTANDING and AUTHORIZATION
and sign below.
A PRE-EXISTING MEDICAL CONDITION EXCLUSION may apply to medical
I understand the necessity of calling Global Excel Management Inc. and obtaining conditions and/or symptoms that existed prior to my trip. I understand that any prior approval before seeking medical attention in case of a claim or medical medical condition I have, including those disclosed in PART C, will be subject to
emergency. The toll free telephone number can be found on my wallet card and in the pre-existing medical condition exclusion(s) of the plan I qualify for. I will refer to my policy and to the above for the full pre-existing medical condition exclusion Medical Authorization in Case of a Claim – I understand that Royal & Sun Alliance Insurance Company of Canada and Global Excel Management Inc. may I personally provided the answers on this medical declaration and all information investigate my claim. By signing this medical declaration, I also hereby direct and disclosed is true and accurate. The Insurer will, in the event of any sickness or injury, authorize any physician, health care practitioner, hospital or other medical care review my prior medical history and my answers. I fully understand that if any of my facility, pharmacy, the Ministry of Health or any other person who has attended and answers are inaccurate, in the event of a claim, the Insurer will void my policy and examined me or who has knowledge or records of me or my health, to furnish to my claim will be refused. I understand that the answers on my medical declaration Royal & Sun Alliance Insurance Company of Canada and to Global Excel are relevant to the risk and constitute the basis of my insurance. Where I was unsure Management Inc. any or all information with respect to my sickness, injury, medical of my medical history as it relates to the medical questions, I have verified it with my history, consultations, medicines or treatment and copies of all hospital or medical records for the purpose of investigating my claim.
O F F I C E U S E O N LY
IMPORTANT - APPLICANT’S SIGNATURE
AGENCY NAME: ________________________________________________________
AGENCY TELEPHONE NUMBER: __________________________________________
AGENCY DISTRIBUTOR NUMBER: ________________________________________
DATE OF SIGNATURE (D/M/Y)
POLICY NUMBER: ______________________________________________________
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Source: http://www.aerosafaris.com/pdf/GT%20Med%20Dec%2060+.pdf