Travel Insurance Eligibility Criteria 55 & Over Questionnaire Form for applicants 55 and overThis Travel 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:*Phone:* Area Code - Phone Number E-mail:*Eligibility:1. You must meet the following conditions to be eligible for this insurance:a) You must be a Canadian resident and be covered by the government health insurance plan (GHIP) of your Canadian province or territory of residence for the entire duration of your trip;b) You must NOT be travelling against the advice of a physician or have been diagnosed with a terminal illness or metastatic cancer;c) You must NOT have a kidney disease requiring dialysis; andd) You must NOT have been prescribed or used home oxygen during the 12 months prior to your date of application.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 90 days prior to each departure date.2. Your heart condition, if any heart condition was not stable at any time during the 90 days prior to each departure date.3. Your lung condition, if:a) Any lung condition was not stable; orb) You have been treated with home oxygen or taken oral steroids (e.g., prednisone) for any lung condition;at any time during the 90 days prior to each departure date.01A. Are you traveling against the advice of a physician?*YesNo01B. 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.*YesNo01C. 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.*YesNo01D. Do you have a Kidney disease requiring dialysis?*YesNo01E. During the 12 months prior to your application date, have you been prescribed or used Home oxygen?*YesNo02. Have you had Heart bypass surgery or Heart angioplasty (including stent placement) more than 12 years ago? *YesNo03. Have you ever had a Bone marrow transplant or an Organ transplant (excluding corneal transplant)?*YesNo04. Do you have a surgically unrepaired Aneurysm of 4.0 cm or more?*YesNo05. In the past 5 years, have you been diagnosed with or treated³ 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)?*YesNo* If you answer YES to ANY question in the previous section, you are NOT ELIGIBLE to purchase this insurance. Other insurance coverage options may be available; please contact your broker or sales agent. 06. In the past 5 years, have you smoked or used any tobacco products?*YesNo07. In the past 10 years, have you been diagnosed with or treated³ for a Heart condition (including stent placement, pacemaker and/or defibrillator)?*YesNo08. In the past 5 years, have you been diagnosed with or treated for:08A. Diabetes or Glucose intolerance (pre-diabetes)?*YesNo08B. Stroke or Mini-stroke (CVA/TIA)?*YesNo08C. Peripheral Vascular Disease (PVD), Carotid Artery Stenosis or any narrowed or blocked artery, excluding coronary artery disease?*YesNo08D. Lung condition (such as any prescription for puffers/inhalers), excluding lung cancer or a minor ailment¹?*YesNo08E. Dementia or Alzheimer's disease?*YesNo08F. Cancer (excluding basal or squamous cell skin cancer)? *YesNo09. In the past 2 years, have you been diagnosed with or treated³ for any of the following: - Chronic bowel disease (such as but not limited to Crohn's disease or Ulcerative colitis)? - Gastrointestinal bleeding, Bowel obstruction or have had Bowel surgery? - Gallbladder disease (including stones)? Not applicable if your gallbladder has been removed. - Kidney disease (including stones), Liver disease or Pancreatitis?*YesNoPart 2 - Do you qualify for Supreme or Elite?10. Has it been more than 24 months since your last regular check-up with a physician? Regular Check-Up means any standard or customary medical examination unrelated to any specific medical condition and which is carried out for the purpose of screening, health monitoring or preventive care and may include routine medical tests and investigations.*YesNo11. In the past 12 months, have you been diagnosed with or treated³ for:11A. High blood pressure?*YesNo11B. High cholesterol?*YesNoSubmit FormReset*By submitting this form you hereby consent to Insufin Inc's right to use the information provided to contact you.