Questionnaire for applicants 54 and Under

Eligibility Criteria: This insurance is only available if you are a Canadian resident covered by the Government Health Insurance Plan of your Canadian province or territory of residence for the entire duration of your trip.

First Name:*
Last Name:*
01A. Are you travelling against the advice of a physician?
01B. Have you ever 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?
01C. Have you ever been diagnosed with Metastatic cancer? Metastatic cancer means a cancer that has spread from its original site to one or more other area(s) of the body?
01D. Do you have a Kidney disease requiring dialysis?
01E. During the 12 months prior to your application date, have you been prescribed or used Home oxygen?

*By submitting this form you hereby consent to Insufin Inc's right to use the information provided to contact you.