Life Insurance Quote

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Personal and Travel Information
First and Last Name:		Telephone #:
Email Address:		Province:
Date of Birth :	(MM/DD/YYYY)	Gender:	Male Female
Departure Date: Return Date: Destination:		Are you topping up another policy? . . . . . . Yes No If yes, number of days covered by other insurance?: Name of plan:

Medical health questionnaire

1 - In the 36 months prior to application, have you been diagnosed with, treated or been ordered by a physician to take medication for, three (3) or more of the following medical conditions? (Please check each condition below, which applies)

Yes No

Heart disease/condition

Liver disease/condition

Lung disease/condition (excluding asthma not requiring prednisone)

Diabetes (requiring medication)

Stroke or mini-stroke (TIA or transient ischemic attack)

2 - In the 12 months prior to application, have you been diagnosed with, treated or been ordered by a physician to take medication for peripheral vascular disease (blocked leg arteries), congestive heart failure, chronic obstructive pulmonary disease (COPD, emphysema)?

Yes No

3 - In the 12 months prior to application, have you used or been prescribed home oxygen?

Yes No

4 - do you have a terminal condition or metastatic cancer?

Yes No

5 - did you have heart bypass surgery more than 10 years before application? (answer "no" to this question if you've had additional bypass surgery and/or placement of a stent less than 10 years prior to application)
Yes No
6 - have you had an organ transplant (excluding cornea or skin graft)?
Yes No
7 - do you have a kidney disease requiring kidney dialysis?
Yes No
8 - do you have an aneurysm larger than four (4) centimetres, measured in either length or diameter?
Yes No
9 - in the 6 months prior to application, hae you had a stroke or mini-stroke (tia or transient ischemic attack)?
Yes No
10 - In the 5 years prior to application, have you been diagnosed with, treated or ordered by a physician to take medication or been hospitalized for any of the following:
Heart attack, aneurysm, angioplasty, atrial fibrillation, artery bypass surgery, cardiac surgery, angina, congestive heart failure, irregular heartbeat, pacemaker, thrombosis, phlebitis, pulmonary oedema	Yes No
Chronic asthma, chronic bronchitis, chronic obstructive pulmonary disease (COPD), emphysema or pneumonia	Yes No
Diabetes (requiring medication)	Yes No
Stroke or mini-stroke (TIA or transient ischemic attack)	Yes No
Peripheral vascular disease or carotid artery stenosis (blocked or clogged arteries in the legs or neck)	Yes No
Liver disease/condition	Yes No
Cancer (excluding basal cell skin cancer)	Yes No
Kidney disease that required dialysis, now no longer on dialysis	Yes No
11 - In the 24 months prior to application, how many of the following medical conditions have you been diagnosed with, treated or ordered by a physician to take medication for?
Kidney disease	Yes No
Gastrointestinal bleeding	Yes No
Alzheimer's disease/dementia	Yes No
Pancreatitis	Yes No
Chronic bowel disease	Yes No
Bowel obstruction	Yes No
12 - In the 12 months prior to application, have you been diagnosed with, or undergone a change in medical treatment (including an alteration in medication dosage or usage) for high blood pressure AND had any of the following conditions?
High cholesterol	Yes No
Diabetes (not requiring medication)	Yes No
Gallbladder disease	Yes No
Osteoporosis	Yes No
Arthritis	Yes No
13 - Have you ever been treated for a heart disease/condition (excluding congenital heart disease)?	Yes No
14 - Was your last regular check-up with a physician more than 24 months ago?	Yes No
15 - Have you had a fall that you reported to a physician in the last 6 months?	Yes No
16 - In the 12 months prior to application, have you smoked tobacco products?	Yes No

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