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Rsatravelinsurance.ca

Application
For Broker / Sales Agent Use Only
Applicant 1 Policy Number:
Applicant 2 Policy Number:
This Application must be completed prior to the effective date. ONLY YOU can complete and sign the Medical Questionnaire, not your spouse, broker
or sales agent. Should you need to make a correction to your answers pertaining to the medical questions in this Application, please call your broker
or sales agent for instructions.

Your personal information is colected for the purpose of providing you with insurance services, claims analysis and payments. A .:Personal Information
For a copy of the etfs Privacy Policy, please see www.etfsinc.com. For Privacy Information, please see www.rsagroup.ca
Applicant 1
Date of Birth (D/M/Y) ______/______/______ Applicant 2
Date of Birth (D/M/Y) ______/______/______ Home Address
Destination Address
Emergency Contact
B .:Definitions
Throughout the Medical Questionnaire, defined words are written in italics. Please refer to them as they are important definitions.
1. Terminal illness: means that you have a medical condition that is cause for a physician
c. There have been no new symptoms, more frequent symptoms or more severe symptoms.
to estimate that you have less than 6 months to live or for which palliative care has d. There have been no test results showing deterioration.
e. There has been no hospitalization or referral to a specialist (made or recommended) and you 2. Metastatic cancer: means a cancer that has spread from its original site to one or more other
are not awaiting the results of further investigations for that medical condition.
5. Minor ailment: means any sickness or injury which does not require: the use of medication for
3. Treated: means that you have been hospitalized, have been prescribed medication (including
a period of greater than 15 days; more than one follow up visit to a physician, hospitalization, prescribed as needed), have taken or are currently taking medication or have undergone a surgical intervention or referral to a specialist; and which ends at least 30 consecutive days prior medical or surgical procedure. Note that Aspirin/Entrophen is not considered treatment.
to the departure date of each trip. However, a chronic condition or complications of a chronic 4. Stable: means any medical condition (other than a minor ailment) for which all the following
condition are not considered a minor ailment.
6. Regular check-up: means any standard or customary medical examination unrelated to
a. There has been no new diagnosis, treatment or prescribed medication.
any specific medical condition and which is carried out for the purpose of screening, health b. There has been no change in treatment or change in medication, including the amount of monitoring or preventive care and may include routine medical tests and investigations.
medication to be taken, how often it is taken, the type of medication or change in treatment frequency or type.
Exceptions: the routine adjustment of Coumadin, Warfarin, insulin or oral medication to control diabetes (as long as they are not newly prescribed or stopped) and a change from a brand name medication to a generic brand medication (provided that the dosage is not modified); Page 1 of 4
I understand that in the event of a claim, the answers I provide herein will be reviewed for accuracy by the Insurer.
If they are inaccurate in any way, my claim will be denied.
C .:Are you eligible?
This insurance is only available if you are a Canadian resident covered by the Government Health Insurance Plan in your province or territory of
residence for the entire duration of your trip.

1. Coverage is NOT AVAILABLE to any individual who: Applicant 1
Applicant 2
• is travelling against the advice of a physician; c Eligible
c Eligible
• has been diagnosed with a Terminal illness or Metastatic cancer;
• has a Kidney disease requiring dialysis;
c Not Eligible
c Not Eligible
• has been prescribed or used home oxygen in the 12 months prior to their application date;
• has been diagnosed with AIDS (Acquired Immune Deficiency Syndrome); or
• has been diagnosed with HIV (Human Immunodeficiency Virus).
Please confirm your eligibility to apply for this insurance.
If you are Eligible, please continue to the next section. If you are Eligible and are applying for the Canada Plan, 55-74 Vacation Plan,
Single Trip Non-Medical Plan or 40-Day PSHCP Plan, please proceed directly to Section H.
D .:Do you require customized Medical Underwriting?
Applicant 1 Applicant 2
2. Have you had Heart bypass surgery more than 10 years prior to your application date
(use the date of the most recent bypass)? 3. Have you had Heart angioplasty (including stent placement) more than 10 years prior to your application date
(use the date of the most recent angioplasty)? 4. Have you ever had a Bone marrow transplant or an Organ transplant (excluding corneal transplant)?
5. Do you have an Aneurysm of 3.5 cm or more which remains surgically unrepaired?
6. During the 5 years prior to your application, have you been diagnosed with or treated for Congestive heart failure or are
you currently taking Lasix, Furosemide or a water pill (excluding a water pill taken for high blood pressure only)?
7. During the 12 months prior to your application, have you had: a. Any Heart condition for which you were hospitalized or required a change in medication?
(Refer to part b. of the stable definition.) b. A Lung condition (including pneumonia) which required hospitalization or treatment with Prednisone
(Deltasone or other generics)?
8. During the 12 months prior to your application, have you been diagnosed with or treated for 3 or more of • Diabetes (treated with oral medication or insulin)
Heart condition (including stent placement,
Peripheral vascular disease
(PVD: narrowing or blockage of any blood vessel) • Stroke or Mini-stroke (CVA/TIA)
Lung condition (including any prescription for puffers/inhalers)
High blood pressure
excluding lung cancer or a minor ailment
If you have answered YES to ANY question in Section D above, please contact your broker or sales agent. Otherwise, please continue.
E .:Which plan do you qualify for?
Applicant 1
Applicant 2
9. During the 2 years prior to your application, have you been diagnosed with or treated for any • Chronic bowel disease (such as but not limited to Crohn’s disease or Ulcerative colitis)?
Gallbladder disease (including stones)? Not applicable if your gallbladder has been removed.
Gastrointestinal bleeding, Bowel obstruction or have had Bowel surgery?
Kidney disease (including stones), Liver disease or Pancreatitis?
10. During the 10 years prior to your application, have you been diagnosed with or treated for a Heart condition (including stent placement, pacemaker and/or defibrillator)?
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Section E - Continued on next page Applicant 1
Applicant 2
11. During the 5 years prior to your application, have you been diagnosed with or treated for: a. Diabetes (treated with oral medication or insulin or controlled by diet) or
Glucose intolerance (pre-diabetes)?
b. Stroke or Mini-stroke (CVA/TIA)?
c. Peripheral vascular disease (PVD: narrowing or blockage of any blood vessel)?
d. Lung condition (such as any prescription for puffers/inhalers) excluding lung cancer or a
e. Dementia or Alzheimer’s disease?
f. Cancer (excluding basal or squamous cell skin cancer or breast cancer treated only with Tamoxifen,
Femara or Arimidex)?
12. Have you ever been diagnosed with or treated for any of the following conditions: • Heart condition (including stent, pacemaker and/or defibrillator)?
Stroke or Mini-stroke (CVA/TIA)?
13. Has it been more than 18 months since your last regular check-up with a physician?
14. During the 12 months prior to your application, have you been diagnosed with or treated for: a. High blood pressure?
b. High cholesterol?
15. During the 5 years prior to your application, have you smoked cigarettes? Total Points (Yes answers for Questions 9 to 14)
F .:Qualification Table
PLEASE INDICATE THE COVERAGE YOU QUALIFY FOR and read the Pre-Existing Medical Condition Exclusions.
Pre-Existing Medical Condition Exclusions
You Qualify Pre-Existing
Total Points
Applicant 1 Applicant 2
This insurance does not cover losses or expenses caused directly or
indirectly, in whole or in part, by:

1. Any sickness, injury or medical condition (other than a minor ailment) that was not stable
at any time during the applicable Pre-Existing Period prior to each departure date.
2. Your heart condition, if any heart condition was not stable at any time during the
applicable Pre-Existing Period prior to each departure date.
3. Your lung condition, if:
a. any lung condition was not stable; or
b. you have been treated with home oxygen or taken oral steroids (e.g., prednisone) for
any lung condition, at any time during the applicable Pre-Existing Period prior to each
departure date.
G .:Agreement, Understanding and Authorization
You must read and understand the importance of each of the following statements and sign below.
• A PRE-EXISTING MEDICAL CONDITION EXCLUSION may apply to medical conditions
I understand the necessity of cal ing Global Excel Management Inc. and obtaining prior
and/or symptoms that existed prior to my trip. I understand that any medical condition I have, approval before seeking medical at ention in case of a claim or medical emergency. The tol free including those disclosed in SECTION E, will be subject to the Pre-Existing Medical Condition
telephone number can be found on my wal et card and in my insurance policy.
Exclusions as stated above. I will refer to my policy and to the above for the full Pre-Existing Medical Authorization in Case of a Claim – I understand that Royal & Sun Alliance Insurance
Company of Canada and Global Excel Management Inc. may investigate my claim. By signing Where I was unsure of my medical history as it relates to the medical questions, I have verified
this Medical Questionnaire, I also hereby direct and authorize any physician, health care it with my physician. I personally provided the answers on this Medical Questionnaire and I practitioner, hospital or other medical care facility, pharmacy, the Ministry of Health or any warrant that all information disclosed herein is correct and complete. In the event of a claim, I other person who has attended and examined me or who has knowledge or records of me or fully understand that the Insurer will review my prior medical history and these answers and, if my health, to furnish to Royal & Sun Alliance Insurance Company of Canada and to Global any of my answers are incorrect or incomplete, the Insurer will void my policy and my claim will Excel Management Inc. any or all information with respect to my sickness, injury, medical be refused, regardless of whether the incorrect or incomplete question is related to the cause history, consultations, medicines or treatment and copies of all hospital or medical records for of my claim. I understand that the answers on my Medical Questionnaire are relevant to the risk the purpose of investigating my claim.
and constitute the basis of my insurance. I understand that some exclusions may apply and affect my coverage. I will read my insurance
Applicant 1 Signature
Applicant 2 Signature
Page 3 of 4
Important Notice
If your health changes or does not remain stable between the date you complete and submit this Medical Questionnaire and your departure date, you must review the medical questions
with your broker or sales agent
to re-assess your eligibility. If you are no longer eligible for the insurance plan you purchased and you fail to contact your broker or sales 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 stable after the effective date, your medical condition may not be
covered (see Pre-Existing Medical Condition Exclusions).
H .:Trip Information
Check the applicable Plan and Qualification you are applying for.
Applicant 1
Applicant 2
Multi-Trip Annual
Multi-Trip Annual
All-Inclusive Multi-Trip Annual
All-Inclusive Multi-Trip Annual
c 40-Day PSHCP Supplemental
c 40-Day PSHCP Supplemental
c Single Trip Daily or Top-Up Plan
c 55-74 Vacation Plan
c Single Trip Daily or Top-Up Plan
c 55-74 Vacation Plan
c Canada Plan
c Single Trip Non-Medical Plan*
c Canada Plan
c Single Trip Non-Medical Plan*
** If you are purchasing a Top-Up to an existing coverage, the Effective Date will be
** If you are purchasing a Top-Up to an existing coverage, the Effective Date will be
the day after your existing coverage terminates.
the day after your existing coverage terminates.
Name of the other Insurer: _________________________________________________ Name of the other Insurer: _________________________________________________ Number of Pre-insured days: ________________ Number of Pre-insured days: ________________ Qualification (For Medical Questionnaire Applicants only)
Qualification (For Medical Questionnaire Applicants only)
c Supreme
c Preferred
c Advantage
c Standard
c Supreme
c Preferred
c Advantage
c Standard
Deductible Options (For Medical Questionnaire Applicants only)
Deductible Options (For Medical Questionnaire Applicants only)
c $250 US (0%)
c $250 US (0%)
Smoker (For Medical Questionnaire Applicants only)
Smoker (For Medical Questionnaire Applicants only)
During the 5 years prior to your application, During the 5 years prior to your application, I .:Premium and Payment
For manual applications, please complete the Premium Calculation page to determine each Applicant’s total premium, or visit www.etfsinc.com/premiumcalculation/index.html If you are applying for the Canada Plan, 55-74 Vacation Plan, Single Trip Non-Medical Plan or 40-Day PSHCP Plan,
complete the Premium Calculation – Plans without Medical Questionnaire page.
If you are applying for all other plans, complete the Premium Calculation – Plans with Medical Questionnaire page.
Total Premium
$ Applicant 1
+ $ Applicant 2
Method of Payment
c Cheque made payable to the broker or sales agent indicated on the front of this application.
Medi-Select Advantage® Travel Insurance is underwritten by Royal & Sun Alliance Insurance Company of Canada and administered by Expert Travel Financial Security (E.T.F.S.) Inc.
® The etfs logo is a registered trademark of Expert Travel Financial Security (E.T.F.S.) Inc.
® Medi-Select Advantage is a registered trademark of Expert Travel Financial Security (E.T.F.S.) Inc.
™ “RSA” and the RSA logo are trademarks owned by RSA Insurance Group plc, licensed for use by Royal & Sun Alliance Insurance Company of Canada.
Page 4 of 4

Source: http://www.rsatravelinsurance.ca/pdfs/eng/msa/1002APMECA0710OPN.pdf

cspsychiatric.com

Cool Springs Psychiatric Group PATIENT HISTORY Patient Name ________________________________ Date of Birth___________Date form completed: _________________________*Please arrive on time and bring this form completed to your appointment to avoidany delay in seeing the doctor*1. What is prompting you to seek help? What do you want to change?_________________________________________________

Microsoft word - aqs.doc

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