GetAwayInsured

Where do you live?

Where are you going?

How long will you be away?

Departure Date

Return Date

Who is traveling?

Name

Phone

Date of birth

Medical Questionnaire

If you are over 60 at the time of travel, a medical questionnaire is mandatory.Have you been prescribed or taken medication, been diagnosed with or had an investigation, medical consultation or treatment for any of the following?

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1. Heart Condition or Cardiovascular Condition

Including but not limited to: Disorders of the Heart Rhythm or Conduction, Atrial Fibrillation, Arrhythmia or Bundle Branch Black, Pacemaker, Ablation or Implantable Cardioverter nDefibrillator

Heart Condition or Cardiovascular Condition:

Yes

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2. Stroke, TIA, Mini-stroke or Cerebrovascular Condition

Stroke, TIA, Mini-stroke or Cerebrovascular Condition:

Yes

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3. Lung Condition

Lung Condition:

Yes

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4. Neurological Condition

Neurological Condition:

Yes

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5. Peripheral Vascular, Artery, Vein Condition or Blood Clots

Peripheral Vascular, Artery, Vein Condition or Blood Clots

Yes

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6. Aneurysm or Arterial Enlargement

Aneurysm or Arterial Enlargement:

Yes

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7. Internal condition, including but not limited to: Disorders of the Stomach, Bowel, Gastrointestinal Tract, Kidney(including stones), Liver, Pancreas, Spleen, Prostate, Urinary Tract nor Gall Bladder(including stones)

Internal condition, including but not limited to: Disorders of the Stomach, Bowel, Gastrointestinal Tract, Kidney(including stones), Liver, Pancreas, Spleen, Prostate, Urinary Tract nor Gall Bladder(including stones):

Yes

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8. Blood Disorder

Blood Disorder:

Yes

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9. Diabetes

Diabetes:

Yes

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10. Cancer

Cancer:

Yes

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11. High Blood Pressure, Low Blood Pressure or Hypertension (including preventative medication)

High Blood Pressure, Low Blood Pressure or Hypertension (including preventative medication):

Yes

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12. High Cholesterol or Low Cholesterol (including preventative medication)

Answer "Yes" if you are taking medication to control your cholesterol or triglycerides

High Cholesterol or Low Cholesterol (including preventative medication):

Yes

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13. Other Medical Conditions

Other Medical Conditions:

Yes

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14. Tobacco Use

Tobacco Use:

Yes

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15. Annual Medical Checkup

Annual Medical Checkup:

Yes

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16. Hospitalization, ER Visit, or Surgery

Have you been hospitalized, visited the emergency room (ER), or had surgery in the last 12 months for any conditions asked about or not asked about?

Yes

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17. Assistance with Activities of Daily Living

Do you require any assistance from another person with Activities of Daily Living?

Yes

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18. Awaiting Surgery, Investigative Testing, or Diagnosis

Are you currently awaiting surgery, investigative testing or a diagnosis of any condition?

Yes

Thanks for filling that out!

A representative will contact you to finalize your quote

Preferred method of contact

📞 phone

📧 e-mail

I have read the statements and hereby confirm eligibility.

Congratulations!

Thanks Mr./Mrs. your information have been submitted successfully for the future reference we will contact you soon.

Give Us A Call 905-493-5060 1-800-387-0339 If you need help or have any questions, please get in touch with us. Our Licensed Brokers will be happy to help you out. Monday - Friday from 9am - 5pm

Where do you live?

Where are you going?

How long will you be away?

Who is traveling?

Medical Questionnaire

1. Heart Condition or Cardiovascular Condition

Heart Condition or Cardiovascular Condition:

Condition Name

Number of Medications

Have you ever had heart bypass surgery?

Have you had an angioplasty or stent insertion?

Have you ever had Congestive Heart Failure (CHF)?

Have you had any change in stability in the last 12 months, including any new symptoms, investigations, diagnosis, or been prescribed or told to take any new medication, told to no longer take a type of medication, or had any dosage adjustments?

When was the most recent change?

Are you prescribed a Nitro spray, patch, or pill?

When was the last time you used your nitro?

Valvular heart disease or surgery

2. Stroke, TIA, Mini-stroke or Cerebrovascular Condition

Stroke, TIA, Mini-stroke or Cerebrovascular Condition:

Condition Name

Number of Medications

Have you had any change in stability in the last 12 months, including any new symptoms, investigations, diagnosis, or been prescribed or told to take any new medication, told to no longer take a type of medication, or had any dosage adjustments?

Have you had any change in stability in the last 12 months, including any new symptoms, investigations, diagnosis, or been prescribed or told to take any new medication, told to no longer take a type of medication, or had any dosage adjustments?

Are you prescribed a Nitro spray, patch, or pill?

3. Lung Condition

Lung Condition:

Condition Name

Number of Medications

Do you take any or use any of the following for your lung condition?

4. Neurological Condition

Neurological Condition:

Condition Name

Number of Medications

Have you had any change in stability in the last 12 months, including any new symptoms, investigations, diagnosis, or been prescribed or told to take any new medication, told to no longer take a type of medication, or had any dosage adjustments?

5. Peripheral Vascular, Artery, Vein Condition or Blood Clots

Peripheral Vascular, Artery, Vein Condition or Blood Clots

Condition Name

Number of Medications

Have you had any change in stability in the last 12 months, including any new symptoms, investigations, diagnosis, or been prescribed or told to take any new medication, told to no longer take a type of medication, or had any dosage adjustments?

6. Aneurysm or Arterial Enlargement

Aneurysm or Arterial Enlargement:

Condition Name

Number of Medications

Have you ever had an aneurysm?

Have you ever had an aneurysm that had been surgically repaired?

Have you had any change in stability in the last 12 months, including any new symptoms, investigations, diagnosis, or been prescribed or told to take any new medication, told to no longer take a type of medication, or had any dosage adjustments?

7. Internal condition, including but not limited to: Disorders of the Stomach, Bowel, Gastrointestinal Tract, Kidney(including stones), Liver, Pancreas, Spleen, Prostate, Urinary Tract nor Gall Bladder(including stones)

Internal condition, including but not limited to: Disorders of the Stomach, Bowel, Gastrointestinal Tract, Kidney(including stones), Liver, Pancreas, Spleen, Prostate, Urinary Tract nor Gall Bladder(including stones):

Condition Name

Number of Medications

If you have a Kidney disorder, do you receive dialysis treatments for kidney or renal failure/deficiency?

Have you had any change in stability in the last 12 months, including any new symptoms, investigations, diagnosis, or been prescribed or told to take any new medication, told to no longer take a type of medication, or had any dosage adjustments?

8. Blood Disorder

Blood Disorder:

Condition Name

Number of Medications

Have you had any change in stability in the last 12 months, including any new symptoms, investigations, diagnosis, or been prescribed or told to take any new medication, told to no longer take a type of medication, or had any dosage adjustments?

9. Diabetes

Diabetes:

How is your diabetes treated?

Number of Medications

Have you had any change in stability in the last 12 months, including any new symptoms, investigations, diagnosis, or been prescribed or told to take any new medication, told to no longer take a type of medication, or had any dosage adjustments?

10. Cancer

Cancer:

Do any of these apply to your type of cancer?

Cancer Location

Number of Medications

Date of Last Treatment

Do you still have annual checkups with the oncologist?

11. High Blood Pressure, Low Blood Pressure or Hypertension (including preventative medication)

High Blood Pressure, Low Blood Pressure or Hypertension (including preventative medication):

Number of Medications

Have you had any change in stability in the last 12 months, including any new symptoms, investigations, diagnosis, or been prescribed or told to take any new medication, told to no longer take a type of medication, or had any dosage adjustments?

12. High Cholesterol or Low Cholesterol (including preventative medication)

High Cholesterol or Low Cholesterol (including preventative medication):

Number of Medications

Have you had any change in stability in the last 12 months, including any new symptoms, investigations, diagnosis, or been prescribed or told to take any new medication, told to no longer take a type of medication, or had any dosage adjustments?

13. Other Medical Conditions

Other Medical Conditions:

Give Us A Call
905-493-5060
1-800-387-0339
If you need help or have any questions, please get in touch with us.
Our Licensed Brokers will be happy to help you out. Monday - Friday from 9am - 5pm