Travel Insurance Quote Request Please enable JavaScript in your browser to complete this form.InstructionsApplicant 1 *FirstLastDate of Birth (1) *Applicant 2 *FirstLastDate of Birth (2) *Province of Residence *AlbertaBritish ColumbiaManitobaNew BrunswickNewfoundland and LabradorNorthwest TerritoriesNova ScotiaNunavutOntarioPrince Edward IslandQuebecSaskatchewanYukonAre you currently in Canada? *YesNoEmail *Phone *Departure Date: *Return Date: *Destination *Number of trips during the year? *What plan are you interested in?: *Single-Trip PlanAnnual Trip PlanAre you planning to return to Canada during your trip? *YesNoPlease provide dates of return to Canada and dates you will return to your vacation destination:Are you topping-up another policy? *YESNOName of Plan?Number of days covered by other insurer?Have you had any change of health or medication alteration in the 180 days prior to departure? If yes, please provide details below including dates: Please enter the name of applicant and description of health changeTIP: MEDICAL QUESTIONNAIRE: What should I do if I don’t know how to answer a question? MEDICAL TERMINOLOGYELIGIBILITY You are eligible to apply for this coverage if you answer NO to the first 3 questions AND confirm Canadian residency in Q.#4 below:A) APPLICANT 1: Are you travelling against your physician's advice? *YESNOA) APPLICANT 2: Are you travelling against your physician's advice? (2) *YESNO B) APPLICANT 1: Have you been diagnosed with a terminal condition? *YESNO B) APPLICANT 2: Have you been diagnosed with a terminal condition? (2) *YESNO C) APPLICANT 1: Are you receiving or been recommended to have palliative care? *YESNOC) APPLICANT 2: Are you receiving or been recommended to have palliative care? (2) *YESNO D) APPLICANT 1: Are you a Canadian resident? *YESNO D) APPLICANT 2: Are you a Canadian resident? (2) *YESNOMEDICAL QUESTIONNAIRE1. Have you experienced any of the following? Choose a condition if, in the specified timeframe, you had the condition, whether or not you received any medical care for it. This includes, in the last 12 months, conditions controlled or managed by medication, a medical device, diet or exercise.1.a APPLICANT 1: Myocardial infarction also known as heart attack? Stroke or Transient Ischemic Attack (TIA) also known as mini-stroke? *Less than 1 year ago1 to 5 years agoMore than 5 years agoNone1.a APPLICANT 2: Myocardial infarction also known as heart attack? Stroke or Transient Ischemic Attack (TIA) also known as mini-stroke? (copy) *Less than 1 year ago1 to 5 years agoMore than 5 years agoNone1.b APPLICANT 1: Arterial by-pass, angioplasty and/or the placement of a stent for a cardiovascular condition? *Less than 1 year ago1 to 5 years agoMore than 5 years agoNone1.b APPLICANT 2: Arterial by-pass, angioplasty and/or the placement of a stent for a cardiovascular condition? (copy) *Less than 1 year ago1 to 5 years agoMore than 5 years agoNone2. APPLICANT 1: Do you currently have hypertension also known as high blood pressure? Choose this condition if, in the specified timeframe, you had the condition, whether or not you received any medical care for it. This includes, in the last 12 months, conditions controlled or managed by medication, a medical device, diet or exercise. *NoYes with NO alteration to your medication in the last 6 monthsYes WITH an alteration to your medication in the last 6 months2. APPLICANT 2: Do you currently have hypertension also known as high blood pressure? Choose this condition if, in the specified timeframe, you had the condition, whether or not you received any medical care for it. This includes, in the last 12 months, conditions controlled or managed by medication, a medical device, diet or exercise. (2) *NoYes with NO alteration to your medication in the last 6 monthsYes WITH an alteration to your medication in the last 6 months3. Have you had any of these conditions in the last 12 months? Choose a condition if, in the specified timeframe, you had the condition, whether or not you received any medical care for it. This includes, in the last 12 months, conditions controlled or managed by medication, a medical device, diet or exercise.APPLICANT 1: CARDIOVASCULAR *Aortic aneurysm that is 4cm or largerAnginaCongestive heart failure also known as pulmonary edemaCoronary Artery Disease (CAD)*Deep Vein Thrombosis (DVT)Arteriosclerosis and/or atherosclerosis also known as hardening of the arteriesPeripheral Vascular Disease (PVD)Atrial fibrillation*High cholesterolNoneAPPLICANT 2: CARDIOVASCULAR (2) *Aortic aneurysm that is 4cm or largerAnginaCongestive heart failure also known as pulmonary edemaCoronary Artery Disease (CAD)*Deep Vein Thrombosis (DVT)Arteriosclerosis and/or atherosclerosis also known as hardening of the arteriesPeripheral Vascular Disease (PVD)Atrial fibrillation*High cholesterolNoneAPPLICANT 1: RESPIRATORY *Asthma requiring prednisoneAsthma NOT requiring prednisoneTwo or more bronchitis episodesPneumoniaChronic Obstructive Pulmonary Disease (COPD), including emphysema, requiring home oxygenChronic Obstructive Pulmonary Disease (COPD), including emphysema, not requiring home oxygenNoneAPPLICANT 2: RESPIRATORY (2) *Asthma requiring prednisoneAsthma NOT requiring prednisoneTwo or more bronchitis episodesPneumoniaChronic Obstructive Pulmonary Disease (COPD), including emphysema, requiring home oxygenChronic Obstructive Pulmonary Disease (COPD), including emphysema, not requiring home oxygenNoneAPPLICANT 1: GASTROINTESTINAL *Peptic ulcer, either stomach or duodenal Crohn’s disease, diverticulitis*, inflammatory bowel disease, bowel obstruction and/or ulcerative colitisGastroesophageal reflux disease (GERD)* also known as chronic acid reflux NoneAPPLICANT 2: GASTROINTESTINAL (2) *Peptic ulcer, either stomach or duodenal Crohn’s disease, diverticulitis*, inflammatory bowel disease, bowel obstruction and/or ulcerative colitisGastroesophageal reflux disease (GERD)* also known as chronic acid reflux NoneAPPLICANT 1: CANCER *Pancreatic cancerLiver cancerAny type of cancer that has metastasized or that required a bone marrow transplant, excluding pancreatic or liver cancerAny other types of cancer. Exclude basal cell and squamous cell skin cancer and/or cancer that is in remissionNoneAPPLICANT 2: CANCER (2) *Pancreatic cancerLiver cancerAny type of cancer that has metastasized or that required a bone marrow transplant, excluding pancreatic or liver cancerAny other types of cancer. Exclude basal cell and squamous cell skin cancer and/or cancer that is in remissionNone4. APPLICANT 1: Have you had any of these conditions in the last 12 months? Choose a condition if, in the specified timeframe, you had the condition, whether or not you received any medical care for it. This includes, in the last 12 months, conditions controlled or managed by medication, a medical device, diet or exercise. *Arthritis*Diabetes requiring insulinDiabetes NOT requiring insulin*Gallbladder disease, including gallstonesHyperthyroidismHypothyroidismKidney stonesKidney disease requiring dialysis Kidney disease NOT requiring dialysisDementia including Alzheimer’s diseaseOsteoporosisParkinson’s Disease (PD)PancreatitisLiver disease, excluding liver cancerTwo or more bladder infections*None4. APPLICANT 2: Have you had any of these conditions in the last 12 months? Choose a condition if, in the specified timeframe, you had the condition, whether or not you received any medical care for it. This includes, in the last 12 months, conditions controlled or managed by medication, a medical device, diet or exercise. (2) *Arthritis*Diabetes requiring insulinDiabetes NOT requiring insulin*Gallbladder disease, including gallstonesHyperthyroidismHypothyroidismKidney stonesKidney disease requiring dialysis Kidney disease NOT requiring dialysisDementia including Alzheimer’s diseaseOsteoporosisParkinson’s Disease (PD)PancreatitisLiver disease, excluding liver cancerTwo or more bladder infections*None5. APPLICANT 1: In the last 12 months, have you smoked any tobacco products, or vaped any nicotine products (including e-cigarettes)? *YESNO5. APPLICANT 2: In the last 12 months, have you smoked any tobacco products, or vaped any nicotine products (including e-cigarettes)? (2) *YESNO6. APPLICANT 1: Have you had any change of health or medication alteration in the past 180 days? IF "Yes", you may be eligible for our exclusive $10 million "Unstable Pre-Existing Condition" rider *YESNO6. APPLICANT 2: Have you had any change of health or medication alteration in the past 180 days? IF "Yes", you may be eligible for our exclusive $10 million "Unstable Pre-Existing Condition" rider (2) *YESNO7. APPLICANT 1: Are you planning any sports activities during your trip?YESNO7.a APPLICANT 1: Which sport activity?7.b APPLICANT 1: Are you interested in our optional rider for any of the sports below? Please select • Backcountry skiing/snowboarding• Base jumping• Boxing• Downhill freestyle skiing/snowboarding in organized competitions• Downhill mountain biking• Hang gliding/paragliding• High risk snowmobiling• Ice climbing• Mixed martial arts• Motorized speed contests• Mountaineering• Parachuting/skydiving/tandem skydiving• Rock climbing• Scuba diving or free diving over 40 metres• White water sports – Class VI• Wingsuit flyingIce HockeyRugbyFootball (Canadian & American)7. APPLICANT 2: Are you planning any sports activities during your trip? (2)YESNO7.a APPLICANT 2: Which sport activity? (2)7.b APPLICANT 2: Are you interested in our optional rider for any of the sports below? Please select (2)• Backcountry skiing/snowboarding• Base jumping• Boxing• Downhill freestyle skiing/snowboarding in organized competitions• Downhill mountain biking• Hang gliding/paragliding• High risk snowmobiling• Ice climbing• Mixed martial arts• Motorized speed contests• Mountaineering• Parachuting/skydiving/tandem skydiving• Rock climbing• Scuba diving or free diving over 40 metres• White water sports – Class VI• Wingsuit flyingIce HockeyRugbyFootball (Canadian & American)8. Would you like a quote for Trip Cancellation/Interruption?YESNOWhat was the date of your initial deposit?What is the amount at risk i.e. prepaid, non refundable deposit(s)? Has anyone who may trigger a claim been stable in the past 60 days? (i.e. no health or medication alteration including decrease, stoppage, change of brand)YESNOPlease provide the names and dates of birth of everyone travelling with you:Compassion ClauseHow did you hear about usI'm an existing clientFriendCanadian MoneySaverCBC "Go Public"CTV NewsROGERS "Daytime Show"Internet SearchName of referring friend or family memberCaptcha * = Submit
