Agaassistance.com.au

CLUB TRAVEL ASSISTANCE
Medical Declaration Form (Under 81 years of age) Effective 28 July 2011
Important information to read before completing this form:
Pre-existing Medical Conditions
Group 2 - Pre-existing Medical Conditions which are automatically covered
- no additional premium is payable.
Please read this section carefully.
You are automatically covered if your Pre-existing Medical Condition is described below, Travel Insurance only provides cover for emergency Overseas medical events that are provided that you have not been hospitalised (including Day Surgery or Emergency Department
unforeseen. Medical conditions that were pre-existing at the time of the policy being issued are attendance) for that condition in the past 24 months. not covered, unless they are a condition that we expressly agree to cover. We do not require any further information or a Medical Declaration Form if your condition is If you have a Pre-existing Medical Condition that is not covered, we will not pay any claims described in this list, and has not caused hospitalisation in the past 24 months: arising from, related to or associated with that condition. This means that you may have to pay for an Overseas medical emergency which can be prohibitive in some countries. What is a Pre-existing Medical Condition?
2. Al ergies limited to Rhinitis, Chronic Sinusitis, (a) An ongoing medical or dental condition of which you are aware, or related complication you have, or the symptoms of which you are aware; b) are less than 60 years of age at the date of (b) A medical or dental condition that is currently being, or has been investigated, or treated by 22. *Hypercholesterolaemia (High Cholesterol) - provided you do not also suf er from a known a health professional (including dentist or chiropractor) at any time in the past, prior to policy 23. *Hyperlipidaemia (High Blood Lipids) - (c) Any condition for which you take prescribed medicine; provided you do not also suf er from a known (d) Any condition for which you have had surgery; 24. *Hypertension (High Blood Pressure) - (e) Any condition for which you see a medical specialist; or provided you do not also suf er from a known 12. *Diabetes Mel itus (Type I) - providing you: 25. Hypothyroidism, including Hashimoto’s Disease The above definition applies to you, your Travel ing Party, a Relative or any other person.
a) were diagnosed over 12 months ago, and * Pregnancy cover is explained on page 17 of the Product Disclosure Statement. b) have no eye, kidney, nerve or vascular Your condition is not a Pre-existing Medical Condition if it arose after the date of issue of How do I obtain cover for my Pre-existing Medical Condition?
hyperlipidaemia or hypercholesterolaemia, If you are aged 81 years or over, the following section does not apply to you. You must
d) are under 50 years of age at the date of complete the ‘81 Years and Over Medical Declaration Form’; available from your Auto Club branch or online from their website. We have the absolute right to accept or decline cover, 13. *Diabetes Mel itus (Type I ) - providing you: or impose special conditions such as an Excess or reduced benefits.
a) were diagnosed over 12 months ago, and If you have a Pre-existing Medical Condition and you want cover for that condition, read b) have no eye, kidney, nerve or vascular the following information. If you have any questions regarding Pre-existing Medical
Conditions, please contact us on 1800 227 771.
Group 1 - Pre-existing Medical Conditions which are automatically excluded
We will not pay any costs or expenses arising directly or indirectly from any of the following Pre- existing Medical Conditions, e.g. cost of medical care while Overseas, or cost of cancellation of 15. Epilepsy - providing there has been no change to 43. Vitamin B12 Deficiency your travel plans due to a change in health. your medication regime in the past 12 months 1. Any type of cancer that you have previously been diagnosed with, or secondaries from that cancer2. Any condition for which surgery/treatment/procedure is planned * Diabetes (Type I and Type I ), Hypertension, Hypercholesterolaemia and Hyperlipidaemia are risk
3. Any condition which arises from signs or symptoms that you are currently aware of, but; factors for cardiovascular disease.
a) You have not yet sought a medical opinion regarding the cause; or If you have a history of cardiovascular disease, and it is excluded under your policy, cover for these
b) You are currently under investigation to define a diagnosis; or conditions is also excluded.
If hospitalisation has occurred, or your condition does not meet the description, cover is not automatic. 4. Any condition for which you have undergone surgery in the past 6 weeks You are required to submit a completed Medical Declaration Form, as explained in Group 3.
5. Any condition for which you have ever required spinal or brain surgery6. Any condition which has caused a seizure in the past 12 months Group 3 - Pre-existing Medical Conditions about which we need further
7. Any Chronic or recurring pain (including back pain) requiring regular medication or other information - require approval and an additional premium is
ongoing treatment such as physiotherapy or chiropractic treatment 8. Any mental illness as defined by DSM-IV including: If your Pre-existing Medical Condition does not fall within Group 1 or 2 and you would like to apply for a) Dementia, depression, anxiety, stress or other nervous condition; or cover for your Pre-existing Medical Condition, we will require you to complete pages 2 and 3 of this form and forward it to us for consideration. We will respond within 1 business day.
b) Behavioural diagnoses such as autism; or c) A therapeutic or illicit drug or alcohol addiction Be aware if you have a Pre-existing Medical Condition and you do not: 9. Any cardiovascular disease or cerebrovascular disease (see example) if you have: (i) apply for and are accepted for cover; and a) Experienced angina (chest pain) within the past 6 months; or (ii) pay the relevant additional premium for the condition, b) Had a stroke (cerebrovascular accident or CVA) or a Transient Ischaemic Attack (TIA) we will not pay any claims related to the Pre-existing Medical Condition. Refer to the PDS under “Your Policy Cover” (pages 29 to 48) and “General Exclusions Applicable
10. Any cardiac or respiratory condition (see examples) if you: to al Sections” (pages 49 to 51).
You cannot apply for cover for conditions outlined in Group 1.
b) will require oxygen for the Journey; or Examples of three (3) common Pre-existing Medical Conditions are set out on page 4.
c) have been diagnosed with Congestive Heart Failure 11. Chronic Renal Failure which is treated by haemodialysis or peritoneal dialysis12. Any AIDS defining illness or any condition associated with immunocompromise13. Organ transplantation, previous organ transplantation, or any condition for which you are 14. Any condition for which you have been given a terminal prognosis for any condition with a Travel insurance is available to you, however there is no provision to claim for any of the medical conditions as listed in the above Group 1.
PAGE 1 This insurance is issued and managed by AGA Assistance Australia Pty Ltd, ABN 52 097 227 177, AFSL 245631 and is underwritten by Allianz Australia Insurance Limited, ABN 15 000 122 850, AFSL 234708
PLEASE COMPLETE THIS FORM IN BLACK INK
CLUB TRAVEL ASSISTANCE
AND FORWARD TO YOUR AUTO CLUB BRANCH
FOR PROCESSING
Auto Club Name:
Consultant’s Name:
Auto Club Phone No:
Medical Declaration Form (Under 81 years of age) Effective 28 July 2011
Disclosure of Pre-existing Medical Conditions
This form should be completed by the traveller. If you do not feel comfortable, or confident answering the medical questions on page 3, you should request
the assistance of your usual doctor. (Any resulting costs incurred are the responsibility of the traveller).
Before continuing, please confirm:

I am less than 81 years of age. (If you are 81 years of age or over, please ask your Auto Club branch for the correct form) I have a Pre-existing Medical Condition and would like to apply for it to be covered. (if not, please reread page 1 or pages 17 to 22 of the PDS to check whether you need to complete this form) We will advise you of the outcome of this assessment in writing within 1 business day provided both pages of the form have been completed in full and signed.
PLEASE USE BLOCK LETTERS (a separate application must be completed for each passenger)
Note: Where there is insufficient space, please attach a separate sheet to provide details
1. Personal Details
Surname:
Male Female Date of Birth: / /
Are you an Australian Citizen or Permanent Resident? Y N
PLEASE NOTE: Pre-existing medical cover is only available to Australian Citizens or Permanent Residents
2. Contact Details
Address:
3. Insurance Details
Cover required: Plan A - Comprehensive Plan B - Australia Only
PLEASE NOTE: Pre-existing Medical Condition Cover is not available on other plans.
Departure Date: / / Return Date: / /
Countries to be visited:
Mode of Travel: Aircraft Car Coach Ship Train Are you intending to: Ski Snowboard Trek (journey on foot with backpacks over a number of days) Hike (one or more isolated long distance walks) Approximate total cost of trip per person – AUD$: 4. Health Details
Height:
Have you ever smoked? Y N
Still a smoker? Y N
If no: How long ago did you cease smoking? Have you ever made any medical travel insurance claims over AUD$1,000 in total? Y N If yes, please provide details:
Have you applied for travel insurance for this journey through another insurer or company? Y N If yes, please provide details:
PAGE 2 This insurance is issued and managed by AGA Assistance Australia Pty Ltd, ABN 52 097 227 177, AFSL 245631 and is underwritten by Allianz Australia Insurance Limited, ABN 15 000 122 850, AFSL 234708
PLEASE COMPLETE THIS FORM IN BLACK INK
CLUB TRAVEL ASSISTANCE
AND FORWARD TO YOUR AUTO CLUB BRANCH
FOR PROCESSING
Auto Club Name:
Consultant’s Name:
Auto Club Phone No:
Medical Declaration Form (Under 81 years of age) Effective 28 July 2011
Traveller’s name:
Date of Birth: / /
This document provides information on which we base our risk assessment decision (i.e. to accept or decline Pre-Existing Medical Conditions) and should be completed by the traveller. If you do not feel comfortable, or confident answering the below medical questions, you should request the assistance of your usual doctor. Any resulting costs incurred are the responsibility of the traveller.
Where there is insufficient space to complete an answer, please provide additional pages with the travellers’ name and date of birth noted.
5. Medical History
Please answer ‘Yes’ or ‘No’ to all questions (a – p) in this section. If you answer ‘Yes’, to any of the questions, please complete all details in that question. Additionally refer to page 4 of this Medical Declaration Form.
a) Have you ever had a blood clot, such as a Deep Vein Thrombosis (DVT) or Pulmonary Embolism?
Reason for clot (eg pregnancy, after surgery, aeroplane journey): What are your planned preventive measures for this journey? b) Do you have HIV infection?
c) Have you ever been diagnosed with a chronic lung disease (including Emphysema and Chronic Bronchitis, Bronchiectasis, COAD (Chronic Obstructive Airways Disease) or COPD (Chronic
Obstructive Pulmonary Disease), Cystic Fibrosis, Asbestosis or Asthma)? What medication do you currently take for this condition? Date you were last in Hospital/Emergency Department with this condition: / / Are bronchodilators or inhaled steriods used? Will you require oxygen for the journey? d) Do you have Diabetes Mellitus?
Currently controlled with: Diet only Insulin injections Insulin pump Other medication Do you have any resulting problems with your: Eyes: Kidneys: Legs (e.g. loss of feeling, ulcers): If yes, please provide details: e) Do you take medication for Hypertension (high blood pressure)?
Y N List medications:
f) Do you take medication for Hypercholesterolaemia (high cholesterol)?
Y N List medications:
g) Have you ever had Angina (chest pain)?
Y N If yes: When was your last attack: / /
h) Have you ever had a heart attack (myocardial infarct)?
i) Have you ever had coronary angiography, stents or bypass grafting (CABG)?
Have you experienced any angina since that procedure? j) Have you ever had a stroke (CVA) or mini-stroke (TIA)?
k) Have you ever been diagnosed with a heart arrhythmia such as atrial fibrillation?
Y N List medications:
l) Do you have a Pacemaker or AICD (internal defibrillator)?
When was the last assessment of the device made by a cardiologist – or is an assessment planned before commencing the trip? / / m) Do you take any other medication for your heart, or to thin your blood?
e.g. Warfarin (also known as Coumadin, Jantoven, Marevan, and Waran) n) Have you ever been diagnosed with epilepsy?
If yes: Have you experienced a seizure in the last 12 months? Have there been any changes to your seizure medication in the last 12 months? o) Have you been hospitalised (including day surgery), or at ended the Emergency Department in the past 24 months? Y N
If yes, please provide details: (If one of these attendances was for a routine colonoscopy, please indicate whether the result was normal) p) Please provide details of any other Pre-existing Medical Conditions (as defined on page 1 of this document) not yet mentioned:
Were any of these conditions newly diagnosed in the last 3 months? 6. Passenger’s Declaration:
I confirm that al my answers are correct and complete. I have read and retained a copy of the Product Disclosure Statement (PDS). I have not withheld any information likely to af ect my application for cover. I authorise any doctor, hospital, clinic or any other person to give AGA Assistance Australia Pty Ltd any medical information (past and current). A photocopy of the authorisation is valid as the original. I have read the Product Disclosure Statement and I consent to the correct use and disclosure of my personal information by Al ianz or AGA Assistance Australia Pty Ltd to such persons and for such purposes stated in the I agree not to be covered for any Pre-existing Medical Conditions unless disclosed in this form and AGA Assistance Australia Pty Ltd has agreed to cover those conditions.
7. Doctor’s Declaration:
Optional- Required only if the answers have been provided by your doctor.
Travel overseas, particularly by commercial aircraft, places significant stress on individuals with a medical condition which may result in decompensation.
This fact must be taken into account when completing this Medical Declaration.
In your opinion is your patient medically fit to undertake the proposed journey without suffering a medical episode? Y N
I hereby declare that the information detailed on this form is accurate and complete and that no information has been withheld which may influence the insurer.
Signature of Physician:
Print Name:
This insurance is issued and managed by AGA Assistance Australia Pty Ltd, ABN 52 097 227 177, AFSL 245631 and is underwritten by Allianz Australia Insurance Limited, ABN 15 000 122 850, AFSL 234708 This insurance is issued and managed by AGA Assistance Australia Pty Ltd, ABN 52 097 227 177, AFSL 245631 and is underwritten by Allianz Australia Insurance Limited, ABN 15 000 122 850, AFSL 234708 CLUB TRAVEL ASSISTANCE
Medical Declaration Form (Under 81 years of age) Effective 28 July 2011
Additional Options
Prolonged travel, particularly at altitude in commercial aircraft, places increased Warfarin Use:
stress upon the cardiovascular and respiratory systems via a number of different Taking the medication Warfarin (also known under the brand names of Coumadin, mechanisms. Despite patients being stable in their normal environment our Jantoven, Marevan, and Waran) has a complex range of serious complications experience over many hundreds of thousands of cases is that there is a quantifiable and side effects. These risks are in excess of those associated with the underlying condition for which you take this medication.
risk associated with your planned trip based on a risk assessment of your past medical history for your cardiovascular or respiratory conditions. If you are currently prescribed the drug, you must complete a Medical Declaration Form (even if you decide not to apply for cover for a Pre-existing Medical Condition) and we must agree in writing to provide cover.
We offer your medical practitioners an opportunity to provide evidence regarding the risk of deterioration during travel. The insurer will then assess the application based If you do not submit a completed Medical Declaration Form, the General Exclusion on this expert advice. Any decision will be based heavily on this advice so we would in clause 17 will apply and you will not have cover.
ask that the opinion offered is considered. This is especially important should in the future the patient suffer an adverse event during the planned travel. Chronic Lung Disease:
If you have ever been diagnosed with a chronic lung disease including (but not
In particular, where the applicant has any of the following issues: limited to) Emphysema and Chronic Bronchitis, Bronchiectasis, Chronic Obstructive • A past history of Deep Vein Thrombosis (DVT) or Pulmonary Embolism, Airways Disease (COAD), Chronic Obstructive Pulmonary Disease (COPD) or • A chronic lung disease (including Emphysema and Chronic Bronchitis, Asthma and you do not purchase adequate cover for your respiratory disease, you Bronchiectasis, COAD (Chronic Obstructive Airways Disease) or COPD (Chronic may not be covered for any claims relating to a new airways infection.
Obstructive Pulmonary Disease), Cystic Fibrosis, Asbestosis and Asthma is If a chronic lung condition is expressly excluded under your policy, all new respiratory infections are also excluded.
• Diabetes (Type I or II) where any nerve, eye or vascular complications has occurred, • Heart problems requiring angiography, stents or bypass grafting (CABG) in the past Privacy Policy
12 months or such procedures were performed more than 10 years ago, • A Cerebrovascular Accident (Stroke) or Transient Ischaemic Attack (TIA) has We (Allianz and our agent AGA Assistance Australia Pty Ltd) require your informed permission to collect, use and disclose your personal information for the following • A Pacemaker or AICD (Internal Defibrillator) has been inserted, • Hospitalisation (including day surgery), or attendance to an Emergency Department has occurred within the past 24 months.
(a) Assessing your request for travel insurance in respect of your known medical As the applicant, you are invited to submit a specialist letter certifying you are (b) Arranging and managing your travel insurance if we accept risk. In the course of medically fit to travel and unlikely to suffer a medical episode arising from this undertaking our functions and activities as stated above, it may be necessary to collect from and disclose to the following third parties your personal information (including sensitive information and health information): Where this information is not supplied with the initial application and we initially
decline your application for cover for your Pre-existing Medical Condition, the
applicant may be requested to supply a specialist letter as outlined above, before any review of the assessment can be completed.
iii. Hospitals and clinics;iv. International assistance providers; and Examples of three (3) common Pre-existing Medical Conditions are set out below:
v. Any other person we deem necessary.
Cardiovascular Disease:
Medical conditions involving the heart and blood vessels are collectively called
Except as stated above or as otherwise required or authorised by law, we will not collect, use or disclose your personal information to any other third party without cardiovascular disease (CVD). All such conditions are interrelated. If you have ever needed to see a specialist cardiologist, or been diagnosed with a form of CVD such your prior knowledge or consent. Collection of your personal information is governed by the Privacy Act 1988 (Cth) and/or with your consent. You are permitted to access your information held by us and should contact our Privacy Officer if you wish to do so or if you have any questions about the way we handle your personal information. If necessary personal information is not provided, we will be unable to 6 Previous heart surgery (including valve replacements, bypass surgery, stents) and you do not purchase adequate cover for CVD, you may not be covered for any claims relating to the heart/cardiovascular system (including heart at acks and strokes).
If any of these conditions are expressly excluded from the policy, al CVD is excluded.
For any Pre-existing Medical questions please call our dedicated
Pre-existing Medical Team on 1800 227 771
PAGE 4 This insurance is issued and managed by AGA Assistance Australia Pty Ltd, ABN 52 097 227 177, AFSL 245631 and is underwritten by Allianz Australia Insurance Limited, ABN 15 000 122 850, AFSL 234708

Source: http://www.agaassistance.com.au/nrmatravel/skins/nrmatravel/pdf/MedicalDeclaration.pdf