Visitor to Canada Eligibility Form

Visitor to Canada Plan Medical Declaration

Answer the following questions to determine eligibility.

First name:*

Last Name:*

Phone:*

Area Code

Phone Number

E-mail:*

Eligibility:

You must:1. Be a visitor to Canada, a person with a Canadian work visa or super visa, an immigrant to Canada or a Canadian resident, who is not eligible for a government health insurance plan in Canada.2. Be at least 15 days of age on the date of purchase.3. NOT be travelling against the medical advice of a physician and/or have been diagnosed with a terminal illness.Terminal illness: 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.4. NOT have a kidney disease requiring dialysis.5. NOT have Congestive Heart Failure or require the use of home oxygen.6. NOT be experiencing new or undiagnosed symptoms and/or know of any reason to seek medical attention.NOTE: Your spouse and/or child(ren) must also meet all the above criteria to be eligible for family coverage. CHILD(REN): Dependent and unmarried child of the insured or his/her spouse, who is at least 15 days old and under 21 years of age on the date of purchase, or a child of any age over 15 days who has a permanent physical impairment or a permanent mental deficiency on the date of purchase and who is dependent on you for support.SPOUSE: Person to whom you are legally married or with whom you have been residing for at least the last 12 months.FAMILY:  You and/or your spouse and your child(ren) when your names appear on the application or confirmation of insurance. Coverage dates are the same for all family members. All family members must live at the same address while in Canada.

01. Within the past 12 months, have you been newly diagnosed with, been prescribed any new medication or change in dosage, frequency or type of medication, had any new or change in treatment (including investigation or testing), been referred to a specialist physician for investigation or testing, or been hospitalized or seen in the emergency department of a hospital, for any of the following: a) a heart condition; b) a lung condition; c) shortness of breath; d) chest pain; e) stroke, mini-stroke or TIA (Transient Ischemic Attack)?*

Yes

02. Have you: a) been diagnosed with a heart valve disorder which has not been treated by heart valve surgery; b) had heart bypass or valve surgery or angioplasty more than 10 years ago? (use the date of your most recent procedure) *

Yes

03. Have you ever been diagnosed with congestive heart failure?*

Yes

04. Within the past 12 months have you: a) been treated for and/or been diagnosed with internal bleeding; and/or b) been admitted to hospital for a gastrointestinal disease or disorder; and/or c) received treatment (including investigation or testing) for any cancer (except basal cell and squamous cell skin cancer)?*

Yes

05. Within the past 12 months, have you been prescribed or taken any of the following: a) Lasix or furosemide for any reason; b) prednisone for any lung condition; c) medications for both diabetes and a heart condition (you can answer no to this question if you are medicated for one of these conditions but not both. Also, medication prescribed solely for the control of blood pressure does not count as a medication for a heart condition); d) any form of nitroglycerin for the relief of angina pain (including on an “as needed” basis)?*

Yes

06. 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?*

Yes

07. Have you ever received an organ transplant? *

Yes

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