Visitors to Canada Travel Insurance Application Form *Applicants can select Plan A or Plan B. Before selecting Plan A or B, read the section “Pre-existing Condition Exclusion” which explains the difference between Plan A and Plan B. *All applicants must complete Parts B, C and D. *For Plan B, applicants 35 years of age and over must also complete Part A. Who can apply?
a) Visitors to Canada;b) Canadians who are not eligible for benefits under a government health insurance plan;c) Persons who are coming to or in Canada on a work visa or Parent and Grandparent Super Visa; ord) New immigrants who are awaiting government health insurance plan coverage. Instructions
Medical questions help us to determine eligibility, assess risk and determine the premium rate that is appropriate. 1. Eligibility – Before completing this application you must determine your eligibility. Carefully read the Eligibility and Plan Qualification section prior to
proceeding. If after reading this section you determine that you are eligible, you qualify for Plan A or Plan B. If you are purchasing Plan A, or if you are under theage of 35 and purchasing Plan B, please complete Parts B, C and D.
2. Those aged 35-85 who are eligible to complete this application may be eligible for Plan B. To be eligible for Plan B, you must answer NO to all of the questions
in Part A • Medical Questionnaire. If you are uncertain of your answers to any of the medical questions, please consult your doctor before completing the Medical Questionnaire section. Coverage Options Single-Trip Coverage – This plan provides emergency medical coverage for one trip only. Coverage begins on the effective date and ends on the termination date as specified on your application and your confirmation of insurance documents. Trip Interruption Coverage – This is an optional benefit and the additional required premium must be paid for coverage to be effective. This benefit covers the non-refundable and non-transferable portion of your trip, should it be interrupted and you are required to return to your home country due to a covered event concerning yourself, an immediate family member or a travel companion. Travel Accident Coverage – This is an optional benefit and the additional required premium must be paid for coverage to be effective. This benefit will cover you for up to $50,000 CDN for an accidental bodily injury or death. Definitions
Italicized words have a specific meaning. Please refer to these definitions when completing the Medical Questionnaire. Activities of daily living means eating, bathing, using the toilet, changing positions (including getting in and out of a bed or chair) and dressing. Change in medication means the medication dosage or frequency has been reduced, increased or stopped, and/or new medications have been prescribed. We do not mean a change from a brand-name drug to an equivalent generic drug of the same dosage, and a routine adjustment in the dosage of your medication, as a result of your blood levels only, if you are taking Coumadin (warfarin) or insulin and are required to have your blood levels tested on a regular basis and your medical condition remains unchanged. Effective date means the date on which your coverage starts. Hospital means a facility that is licensed as a hospital where in-patients receive medical care and diagnostic and surgical services under the supervision of a staff of physicians with 24-hour care by registered nurses. A clinic, an extended or palliative care facility, a rehabilitation establishment, an addiction centre, a convalescent, rest or nursing home, home for the aged or health spa is not a hospital. Medical condition means accidental bodily injury, illness or disease; symptom(s); complication of pregnancy within the first 31 weeks of pregnancy; a mental or emotional disorder that requires admission to a hospital, or acute psychosis. Pre-existing condition means a medical condition that exists before your effective date. Stable medical condition means that:
you have not had a new symptom(s); andexisting symptom(s) have not become more frequent or severe; andyour physician has not found that your medical condition has become worse; andno test findings have shown that your medical condition may be getting worse; andyou have not received, been prescribed, taken or had a physician recommend any new medication, or any change in medication; andyou have not received, been prescribed, or had a physician recommend any new treatment or any change in treatment; andyou have not been hospitalized or referred to a specialist or specialty clinic; andyour physician has not advised you to see a specialist or to have further tests, and you have not undergone testing for which you have not yet received the results. Treatment means a medical, therapeutic or diagnostic procedure prescribed, performed or recommended by a licensed medical practitioner, including but not limited to prescribed medication, investigative testing and surgery related to any illness, injury or symptom. Pre-existing Condition Exclusion
The pre-existing condition exclusion that applies depends on your age and the plan you have qualified for as determined by your answers to the medical questions. Plan A Up to age 85: We will not pay any expenses relating to any medical condition, diagnosed or undiagnosed, which existed or for which you sought or received medical advice, consultation, investigation, or for which treatment was required or recommended by a physician, in the 180 days before your effective date of insurance; any heart condition if, in the 180 days before the effective date, you require any form of nitroglycerine for the relief of angina pain; any lung condition if, in the 180 days before the effective date, you require treatment with oxygen or prednisone for a lung condition. Plan B Up to age 85: We will not pay any expenses relating to a pre-existing condition that is not stable in the 180 days before your effective date; any heart condition if, in the 180 days before the effective date, you require any form of nitroglycerine for the relief of angina pain; any lung condition if, in the 180 days before the effective date, you require treatment with oxygen or prednisone for a lung condition. ALL PLANS & ALL AGES Hospitalization for a pre-existing condition: We will not pay any expenses relating to a pre-existing condition for which you are hospitalized either more than once or for at least 2 consecutive days in the 12 months before your effective date. Eligibility and Plan Qualification COVERAGE ELIGIBILITY You are not eligible for coverage under this policy if any of the following apply to you:
You are travelling against the advice of a physician; You have been diagnosed with a terminal illness with less than 2 years to live; You have a kidney condition requiring dialysis; You have used home oxygen during the 12 months prior to the date of application; You have been diagnosed with Alzheimer's disease or any other form of dementia; You are under 30 days or over 85 years of age (over 69 years of age for $150,000 Single-Trip Emergency Medical Coverage); You reside in a nursing home, home for the aged, other long-term care facility or rehabilitation centre; and/or You require assistance with activities of daily living.
After reading the above, if you determine that you are eligible, you qualify to purchase this insurance. If you are purchasing Plan A, or if you are under the age of 35 andpurchasing Plan B, please complete Parts B, C, and D.
If you are eligible to purchase this coverage and are aged 35-85 (35-69 years of age for $150,000 Single-Trip Emergency Medical coverage) you may qualify for Plan B,which covers stable pre-existing medical conditions that have been stable for 180 days before your effective date. If you are applying for Plan B, you must answer NOto each question in Part A below. If you are uncertain of your answers to any of the medical questions below, please consult your doctor before completing the MedicalQuestionnaire. Part A • Medical Questionnaire ELIGIBILITY QUESTIONS FOR PLAN B, if you are 35 years of age or older Applicant 1 Applicant 2
1. Have you: had heart bypass or valve surgery before 2001?
2. Do you: have BOTH diabetes (for which you require the use of medication) AND a heart condition?
3. Have you ever: received an organ transplant?
4. In the past 2 years, have you:
a) been prescribed or taken Lasix or furosemide for any condition; and/or b) had congestive heart failure; and/or c) required treatment with oxygen or prednisone (or other oral steroid medication,
not including puffers) for a lung condition?
5. In the past 12 months, have you:
a) started treatment for and/or been diagnosed with a heart attack; stroke; transient ischemic attack (TIA);
mini-stroke; or internal bleeding; and/or
b) been diagnosed with cancer, or received chemotherapy or radiotherapy or any other treatment of cancer; and/or c) been hospitalized for 24 hours or more for a gastrointestinal disease or disorder?
If you answered YES to ANY of the PLAN B eligibility questions, you are not eligible to purchase PLAN B. If you answered NO to ALL the PLAN B eligibility questions, you are eligible to purchase PLAN B. Please complete the statement below and proceed to complete Parts B, C, and D. I declare that all the information I have provided on this Medical Questionnaire is true and complete and that I qualify for: Applicant 1: Name:_____________________________
q Plan A q Plan B Signature ________________________________ Dated _________________
Applicant 2: Name:_____________________________
q Plan A q Plan B Signature ________________________________ Dated _________________
Part B • Insurance Application PERSONAL INFORMATION – Please use another application form if there are more than 2 applicants. NAME OF APPLICANTS (Last Name, First Name) DATE OF BIRTH 1. Applicant 1 2. Applicant 2 3. Dependent child 4. Dependent child 5. Dependent child HOME ADDRESS Street Apt No. City Country ADDRESS IN CANADA Street Apt No. City Province Postal Code HOME PHONE #EMERGENCY CONTACT IN CANADA ( ) Name Relationship Phone ( ) ARRIVAL DATE IN CANADA DATE OF APPLICATION COVERAGE SELECTION SINGLE-TRIP PLANS EMERGENCY MEDICAL – COVERAGE REQUESTED:
q Single Coverage OR q Family Coverage (up to age 59)
q Single Coverage OPTIONAL INSURANCE – SINGLE-TRIP TRAVEL ONLY TRIP INTERRUPTION TRAVEL ACCIDENT
q Single Coverage OR
q Family Coverage (up to age 59)
q Single Coverage
q Family Coverage (up to age 59) DURATION OF COVERAGE For Single-Trip Plan Plus Last Day Plus No. of days between Effective and Return Date Equals Total no. of days of coverage Part C • Premium Calculation
The following calculation tables apply only if all applicants purchase the same plan and have the same deductible option. Otherwise, please use a separate application form for each applicant. Determine Your Premium – The premium due for your coverage is based on the plan you are purchasing, your age and trip duration. Please refer to the Rate Chart and enter the applicable premium. For Single-Trip Plans, multiply the number of days of coverage required (Line A) by the appropriate “per day” premium rate provided on the rate chart. EMERGENCY MEDICAL Applicant # of Days x Premium Per Day Premium Family Coverage 2x the Premium Rate of the Oldest (under age 60) $ Total Premium (total premium rates of each applicant or Family Coverage Premium) = $ DEDUCTIBLE SURCHARGE/SAVINGS FACTOR: All Emergency Medical published rates include a $75 deductible. You may choose one of the following deductible options for Single-Trip Emergency Medical plans:
u r c h a r g e 1 . 0 0 f a c t o r $ 1 , 0 0 0
% s a v i n g s 0 . 6 5 f a c t o r X factor
TOTAL EMERGENCY MEDICAL PREMIUM= $ Line B Part C • Premium Calculation (continued) TRIP INTERRUPTION Applicant # # of Days x Premium Per Day Premium Family Coverage 3 x the Premium Rate of the Oldest (under age 60) Total Premium (total premium rates of each applicant or Family Coverage Premium) = $Line C TRAVEL ACCIDENT Applicant # # of Days x Premium Per Day Premium Family Coverage 3x the Premium Rate of the Oldest (under age 60) $ Total Premium (total premium rates of each applicant or Family Coverage Premium) = $ Line D TOTAL PAYMENT Total Premium from Lines B, C and D $ Payment Option: q Visa q MasterCard q American Express q Cheque (payable to your broker/advisor or mail to Manulife Financial Travel Insurance,
P.O. Box 4262, Stn A, Toronto, ON M5W 5T4)
Cardholder’s Name Cardholder’s Signature
Note: Coverage will not take effect if your credit card number is invalid or payment is rejected for any reason. Part D • Applicant’s Declaration – All Applicants Must Complete This Section Declaration. I apply to The Manufacturers Life Insurance Company (Manulife Financial) for insurance under the Manulife Financial Visitors to Canada Travel Insurance policy. I declare that all the information I have provided on this application form, together with the Medical Questionnaire originally attached hereto, is true and complete. I understand that this coverage is subject to conditions, restrictions, limitations and exclusions and may limit or exclude an amount payable. I understand that if I misrepresent any material information provided in this application, Manulife Financial will void my policy and I will not be covered for any benefits under this policy. Authorization and Revocation. I authorize any hospital, physician, other medical service provider or any other organization or person that has any records or knowledge of me or my health to release to Active Care Management and/or Manulife Financial and its reinsurers any such information for the purpose of this application and contract and any subsequent claim. A photocopy or facsimile of this authorization is as valid as the original. I authorize Manulife Financial to use the information in this application and its existing files to offer me their products and services. I understand that my consent to the use of such information to offer me products and services is optional and that if I wish to discontinue such use, I may write to Manulife Financial at the address shown below.
Notice on Privacy and Confidentiality. The specific and detailed information requested on the application form is required to process the application. To protect the confidentiality of this information, Manulife Financial will establish a "financial services file" from which this information will be used to process the application, offer and administer services and process claims. Access to this file will be restricted to those Manulife Financial employees, mandataries, administrators or agents who are responsible for the assessment of risk (underwriting), marketing and administration of services and the investigation of claims, and to any other person you authorize or as authorized by law. These people, organizations and service providers may be in jurisdictions outside Canada, and subject to the laws of those foreign jurisdictions. Your consent to the use of personal information to offer you products and services is optional and if you wish to discontinue such use, you may write to Manulife Financial at the address shown below. Your file is secured in our offices or those of our administrator or agent. You may request to review the personal information it contains and make corrections by writing to: Privacy Officer, Affinity Markets, Manulife Financial, 2 Queen Street East, Toronto, Ontario M5C 3G7. Advisor’s Report • For Advisor/Agent Use Only
You confirm that you have disclosed the following information to the applicant:
the name of the company or companies you represent that you receive commissions for the sale of life and accident and sickness insurance products and may receive bonuses, invitations to conferences or other incentives; and any conflicts of interest you may have with respect to this transaction. Agent – Please complete this section Mail this application form with your payment to your agent/broker or: Manulife Financial Travel Insurance, P.O. Box 4262, Stn A, Toronto, ON M5W 5T4.
Manulife Financial Travel Insurance is offered through The Manufacturers Life Insurance Company (Manulife Financial).
Manulife, Manulife Financial, the Manulife Financial For Your Future logo and the Block Design are trademarks of The Manufacturers Life Insurance Company and are used by it, and by its af iliates under license. 2013 The Manufacturers Life Insurance Company. Al rights reserved. AT0148E-09/13
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