Wholesalers application_01_10_v

MEDICAL QUESTIONNAIRE AND APPLICATION FORM
Instructions
Medical questions help us to determine your eligibility and premium rate if you are age 55 or over.
1. If you are under the age of 55, proceed to Part C to complete the application.
2. If you are applying for the Quick Trip Plan, you must be 55 to 74 years of age and travelling for 17 days or less. You do not need to complete the Medical Questionnaire in Part A. If you are purchasing the Quick Trip Plan, you qualify for Rate Category D in which case, you will not be covered for any expenses relating to: a pre-existing condition for which you have taken, received or been prescribed medication or treatment in the three (3) months before your effective date; and/or your heart condition if, in the three (3) months before your effective date, you have taken, received or been prescribed medication or treatment or you have takenany form of nitroglycerine for the relief of angina pain; and/or your lung condition if, in the three (3) months before your effective date you have taken, received or been prescribed medication or treatment or you requiredtreatment with oxygen or prednisone for your lung condition.
Complete Part C of this application.
3. All other applicants must complete the medical questionnaire in Part A and the Applicant’s Declaration in Part B to apply for this insurance. If you are uncertain of your answers to any medical questions, please consult your doctor before completing this medical questionnaire.
4. All applications must be completed before the effective date of insurance.
Plan Information
Emergency Medical Single Trip Plan – Provides coverage for a single trip while travelling outside your province or territory of residence.
Emergency Medical Multi-Trip Plan – Provides coverage for any number of trips up to the option you selected ( 4, 10, 18 or 30 days). Trips must be separated by
a return to your province or territory of residence or Canada. The Multi-Trip Plans offer unlimited travel within Canada (excluding your province or territory of residence).
Travel Canada Emergency Medical Plan – Provides coverage for a single trip while travelling within Canada and outside your province or territory of residence.
Quick Trip Plan – Provides coverage for a single trip while travelling outside your province or territory of residence, up to 17 days, if you are between ages 55 and 74.
Quick Trip Canada Plan – Provides coverage for a single trip while travelling within Canada and outside your province or territory of residence, up to 17 days, if you
are between ages 55 and 74.
Definitions
Italicized words have a specific meaning. Please refer to the following definitions when completing the Medical Questionnaire.
Change in medication means the medication dosage or frequency has been reduced, increased, or stopped and/or new medication(s) has/have been prescribed.
Exceptions: the routine adjustment of Coumadin, warfarin or insulin, (as long as they are not newly prescribed or stopped) and there has been no change in your
medical condition; and a change from a brand name medication to a generic brand medication of the same dosage.
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 injury, illness or disease, complication of pregnancy within the first thirty-one (31) weeks of pregnancy, or a mental or emotional disorder
that requires admission to a hospital, or acute psychosis.
Medical emergency means a sudden unforeseen occurrence of symptoms, injury, illness, or disease which requires immediate treatment.
Pre-existing condition means a medical condition that existed before your effective date.
Stable – a medical condition is stable if all of the following apply during the specified stability period:
you have not had any new symptom(s); and existing symptom(s) have not become more frequent or severe; and your physician has not determined that your medical condition has become worse; and no test findings have shown that your medical condition may be getting worse; and you have not received, been prescribed, taken or had a physician recommend any new medication, any change in medication; andyou have not received, been prescribed or had a physician recommend any new treatment or any change in treatment; and you have not been hospitalized or referred to a specialty clinic or specialist; 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.
Part A • Medical Questionnaire
NAME OF APPLICANTS (Last Name, First Name)
Step 1 • ELIGIBILITY
Applicant 1
Applicant 2
1. Have you been advised by a physician not to travel at this time? 3. Have you ever had a bone marrow or organ transplant (excluding corneal transplant)?
4. Have you had a heart bypass, angioplasty or heart valve surgery more than ten (10) years ago?
5. In the last five (5) years, have you been diagnosed with and/or had treatment for metastatic cancer?
6. In the last six (6) months, have you received chemotherapy and/or radiotherapy and/or other treatment, other than routine
follow-up, for cancer (except basal cell and squamous cell skin cancer, and breast cancer treated only with hormonal therapy)? 7. In the last twelve (12) months, have you been prescribed or taken prednisone or oxygen or been hospitalized
(as an in-patient or seen in the emergency department) for a lung condition? 8. In the last two (2) years, have you: a) been prescribed or taken Lasix or furosemide for any reason?
9. In the last twelve (12) months, have you been hospitalized (as an in-patient or seen in the emergency department)
10. In the last four (4) months, have you been prescribed or taken six (6) or more prescription medications?
Do not count the following medications: hormone replacement therapy (thyroid or menopausal); drugs used
for osteoporosis, or traveller’s diarrhea; or any form of immunization. Do not count topical medications that go
in your nose, ears or eyes or on your scalp or skin except: any form of nitroglycerine or any drug(s) for angina.
11. In the last three (3) years, have you been diagnosed with and/or had treatment for and/or been hospitalized
(as an in-patient or seen in the emergency department) and/or been prescribed or taken medication for any two (2) of the
following? (if you only have one (1) of the following conditions, answer NO)
Lung condition (medication includes any puffer(s)/inhaler(s),except a single unrepeated prescription medication used for a single episode)
Diabetes (treated with medication and/or insulin) Stroke/CVA (cerebrovascular accident) or mini-stroke/TIA (transient ischemic attack) (including use of aspirin/Entrophen for this condition) Narrowed or blocked artery in the legs (also called Peripheral Vascular Disease) Alzheimer’s disease, or any other form of dementia ELIGIBILITY REQUIREMENT: If you must answer “YES” to ANY of the preceding questions, you are not eligible to purchase this insurance. DO NOT complete this questionnaire.
Please contact your agent/broker if you wish to obtain a quote for our Individual Medical Underwriting plan. Continue to Step 2 if you are eligible to purchase this insurance.
Step 2 • FIND YOUR RATE CATEGORY
RATE QUALIFICATION • Part 1
Applicant 1
Applicant 2
1. In the last five (5) years, have you been diagnosed with and/or had treatment and/or been hospitalized (as an in-patient
or seen in the emergency department) and/or been prescribed or taken medication for any of the following? Stroke/CVA (cerebrovascular accident) or mini-stroke/TIA (transient ischemic attack) (including use of aspirin/Entrophen for this condition) Narrowed or blocked artery in the legs (also called Peripheral Vascular Disease) Diabetes (if treated with medication and/or insulin) Lung condition (medication includes any puffer(s)/inhaler(s),except a single unrepeated prescription medication used for a single episode)
Alzheimer’s disease, or any other form of dementia, or Parkinson’s disease 2. In the last five (5) years, have you smoked or used any tobacco products and been prescribed or used any puffer(s)/inhaler(s)?
3. In the last six (6) months, have you received advice or treatment for a medical emergency more than once in the
4. In the last three (3) months , have you been prescribed or taken a total of three (3) or more medications for high blood
pressure (hypertension) and/or a heart condition? If you answered “YES” to ANY of the questions in Step 2 • Part 1, you qualify for Rate Category C.
If you answered “NO” to ALL of the questions in Step 2 • Part 1, you must answer the question in Step 2 • Part 2.
RATE QUALIFICATION • Part 2
Applicant 1
Applicant 2
1. In the last two (2) years, have you been diagnosed with and/or received treatment for and/or been hospitalized (as an in-patient
or seen in the emergency department) and/or been prescribed or taken prescription medication for any of the fol owing conditions? Diverticular disorder requiring prescription medication or surgery Gallbladder disorder (including stones; if gallbladder has been removed answer NO)
If you answered “YES” to two (2) or more conditions listed in Step 2 • Part 2, you qualify for Rate Category C.
If you answered “YES” to one (1) condition listed in Step 2 • Part 2, you qualify for Rate Category B.
If you answered “NO” to ALL of the conditions listed in Step 2 • Part 2, you must answer the questions in Step 2 • Part 3.
RATE QUALIFICATION • Part 3
Applicant 1
Applicant 2
1. In the last two (2) years, have you been diagnosed with, and/or been hospitalized (as an in-patient or seen in the emergency
department), and/or received treatment, and/or been prescribed medication by a Hematologist or an Internist for a blood disorder? 2. In the last twelve (12) months, have you been prescribed or used a puffer/inhaler?
3. In the last twelve (12) months, have you been diagnosed with or received treatment for cancer, other than routine
follow-up (except basal cell and squamous cell skin cancer, and breast cancer treated only with hormonal therapy)?
4. Are you over 70, and have you had a fall for which you sought medical attention in the last six (6) months?
If you answered “YES” to ANY of the questions in Step 2 • Part 3, you qualify for Rate Category B.
If you answered “NO” to ALL of the questions in Step 2 • Part 3, you must answer the question in Step 2 • Part 4.
RATE QUALIFICATION • Part 4
Applicant 1
Applicant 2
1. In the last two (2) years, have you smoked cigarettes?
If you answered “YES” to the question in Step 2 • Part 4, you qualify for Rate Category A.
If you answered “NO” to the question in Step 2 • Part 4, you qualify for Rate Category A+.
IMPORTANT: The rate category you qualify for determines the pre-existing condition exclusion that applies to your coverage.
The pre-existing condition exclusions are detailed below.
RATE CATEGORY
I am 55 years of age or older and based on my answers above, I qualify for the following rate category:
Applicant 1:
Applicant 2:
Pre-existing Condition Exclusion
The pre-existing condition exclusion which applies to you depends on your Rate Category as determined by the answers to the medical questions in Part A.
All applicants 54 years of age or less automatically qualify for Rate Category A.
Rate Categories A+ and A. We will not pay any expenses relating to:
a pre-existing condition that is not stable in the three (3) months before your effective date; and/or,
your heart condition if, in the three (3) months before your effective date, it has not been stable or you have taken any form of nitroglycerine for the relief of angina pain; and/or,
your lung condition if, in the three (3) months before your effective date, it has not been stable or you required treatment with oxygen or prednisone for your lung condition.
Rate Category B. We will not pay any expenses relating to:
a pre-existing condition that is not stable in the six (6) months before your effective date; and/or,
your heart condition if, in the six (6) months before your effective date, it has not been stable or you have taken any form of nitroglycerine for the relief of angina pain; and/or,
your lung condition if, in the six (6) months before your effective date, it has not been stable or you required treatment with oxygen or prednisone for your lung condition.
Rate Category C. We will not pay any expenses relating to:
a pre-existing condition that is not stable in the twelve (12) months before your effective date; and/or,
your heart condition if, in the twelve (12) months before your effective date, it has not been stable or you have taken any form of nitroglycerine for the relief of angina pain; and/or,
your lung condition if, in the twelve (12) months before your effective date, it has not been stable or you required treatment with oxygen or prednisone for your lung condition.
Part B • Applicant’s Declaration – Please read carefully before signing
Declaration. I apply to The Manufacturers Life Insurance Company (Manulife Financial) for insurance under the Manulife Financial Travel Insurance policy. I declare that all the
information I have provided on this application form, together with the Health Declaration originally attached hereto, is true and complete. I understand that this coverage is subject
to terms, conditions, limitations and exclusions (including the pre-existing condition exclusion) and may exclude or limit an amount payable if I have a claim. 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. 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 the assistance and
claims service provider and/or Manulife Financial and its reinsurers any such information for the purpose of this application and contract and any subsequent claim.
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 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
Medi-Quote Insurance Brokers
1-800-661-3098
1-877-259-2918
Company name and address 205-259 Midpark Way SE
505 Pandora Avenue West
Calgary, AB T2X 1M2
Winnipeg, MB R2C 1M8
info@mediquote.ca
Part C • Insurance Application
APPLICANTS
LAST NAME, FIRST NAME
DATE OF BIRTH
1. Applicant 1
HOME ADDRESS
Street Apt No. City Province Postal Code
HOME PHONE # WORK PHONE # EMAIL (optional) COUNTRY OF DESTINATION PHONE # AT DESTINATION
( ) ( ) ( )
LAST NAME, FIRST NAME
DATE OF BIRTH
2. Applicant 2
HOME ADDRESS
Street Apt No. City Province Postal Code
HOME PHONE # WORK PHONE # EMAIL (optional) COUNTRY OF DESTINATION PHONE # AT DESTINATION
( ) ( ) ( )
COVERAGE SELECTION
MULTI-TRIP DURATION and EFFECTIVE DATE
Covers multiple trips during a 365-day period. SELECT YOUR TRIP LENGTH: q 4 days
EFFECTIVE DATE: _______________________
SINGLE-TRIP DURATION TOP-UP DURATION
TOP-UP NOTE:
Subtract
# of days already covered under your policy 1 Count the day you leave and the day you return.
CALCULATE YOUR PREMIUM
Premium due for your coverage is based on the plan you are purchasing, your age, the Rate Category you qualify for and trip duration.
EMERGENCY MEDICAL Total Emergency Medical Premium
Applicant # Rate Category Single-Trip or Top-Ups Multi-Trip
(# of days x daily rate applicable to your full trip length)2 Rate for the trip length you select Total Premium (sum premium rates of each applicant)
= $ Line A = $ Line A
2 For Top-Up Premium use the daily rate applicable to the TOTAL NUMBER OF DAYS IN YOUR TRIP.
SAVINGS OPTIONS Savings Applied
Deductible Savings: All published rates include a zero deductible. Not applicable to Travel Canada. Deductible ($ USD) $0 $500 $1,000 $5,000 $10,000 50% Travel Canada Emergency Medical or Quick Trip Canada Plan: Cannot be combined with a Deductible Savings. Calculate Savings (% x Line A) = $ Line B
TOTAL PREMIUM
Emergency Medical Premium (Line A minus Line B) = $ Travel Companion Savings (Line C x 5%) = $ If you need help with your premium calculation, please contact your broker/advisor. Total Payment (Line C minus Line D) = $
Payment Option: q Visa q MasterCard q AMEX q Cheque
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.
Mail this application with your payment payable to your agent/broker or Manulife Financial Travel Insurance, P.O. Box 4262, Stn A, Toronto, ON M5W 5T4.
Manulife Financial Travel Insurance is of ered through The Manufacturers Life Insurance Company (Manulife Financial).
Plans underwrit en by The Manufacturers Life Insurance Company. 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. ™/® Trademarks held by The Manufacturers Life Insurance Company. 2013 The Manufacturers Life Insurance Company. Al rights reserved.

Source: http://www.mediquote.ca/sites/default/files/Documents/MQ/Manulife%20Application%20effective%20Dec%206,%202013.pdf