Coveryou.ca

Application
For Broker / Sales Agent Use Only
Applicant 1 Policy Number:
Applicant 2 Policy Number:
Your personal information is colected for the purpose of providing you with insurance services, claims analysis and payments. For a copy of the etfs Privacy Policy, please see www.etfsinc.com. For Privacy Information, please see www.rsagroup.ca.
A .:Are you eligible?
You must meet the following criteria to be eligible for this insurance: 4. You must NOT have been prescribed or used home oxygen during the 12 months prior to your 1. 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.
5. You must NEVER have been diagnosed with AIDS (Acquired Immune Deficiency Syndrome) or 2. You must NOT be travelling against the advice of a physician or have been diagnosed with a terminal illness or metastatic cancer. 3. You must NOT have a kidney disease requiring dialysis.
B .:Definitions
Throughout the Application, defined words are written in italics. Please refer to them as they are important definitions.
1. Terminal illness: means that you have a medical condition that is cause for a physician
c. There have been no new symptoms, more frequent symptoms or more severe symptoms.
to estimate that you have less than 6 months to live or for which palliative care has d. There have been no test results showing deterioration.
e. There has been no hospitalization or referral to a specialist (made or recommended) and you 2. Metastatic cancer: means a cancer that has spread from its original site to one or more other
are not awaiting the results of further investigations for that medical condition.
4. Minor ailment: means any sickness or injury which does not require: the use of medication for
3. Stable: means any medical condition (other than a minor ailment) for which all the following
a period of greater than 15 days; more than one follow up visit to a physician, hospitalization, surgical intervention or referral to a specialist; and which ends at least 30 consecutive days prior a. There has been no new diagnosis, treatment or prescribed medication.
to the departure date of each trip. However, a chronic condition or complications of a chronic b. There has been no change in treatment or change in medication, including the amount of condition are not considered a minor ailment.
medication to be taken, how often it is taken, the type of medication or change in treatment frequency or type.
Exceptions: the routine adjustment of Coumadin, Warfarin, insulin or oral medication to control diabetes (as long as they are not newly prescribed or stopped) and a change from a brand name medication to a generic brand medication (provided that the dosage is not modified); C .:Pre-Existing Medical Condition Exclusions
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
3. Your lung condition, if:
time during the 180 days prior to each departure date.
a. any lung condition was not stable; or
2. Your heart condition, if any heart condition was not stable at any time during the 180 days prior
b. you have been treated with home oxygen or taken oral steroids (e.g., prednisone) for any
lung condition, at any time during the 180 days prior to each departure date.
Medi-Select Advantage® Travel Insurance is underwritten by Royal & Sun Alliance Insurance Company of Canada and administered by Expert Travel Financial Security (E.T.F.S.) Inc.
® The etfs logo is a registered trademark of Expert Travel Financial Security (E.T.F.S.) Inc.
® Medi-Select Advantage is a registered trademark of Expert Travel Financial Security (E.T.F.S.) Inc.
™ “RSA” and the RSA logo are trademarks owned by RSA Insurance Group plc, licensed for use by Royal & Sun Alliance Insurance Company of Canada.
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D .:Personal Information
Applicant 1
Date of Birth (D/M/Y) ______/______/______ Applicant 2
Date of Birth (D/M/Y) ______/______/______ Home Address
Destination Address
Emergency Contact
Dependents
Date of Birth (D/M/Y) ______/______/______ Date of Birth (D/M/Y) ______/______/______ Date of Birth (D/M/Y) ______/______/______ If additional space is required, please attach an additional sheet of paper.
E .:Trip Information
Check the applicable Plan you are applying for.
Applicant 1
Applicant 2
Multi-Trip Annual
Multi-Trip Annual
All-Inclusive Multi-Trip Annual
All-Inclusive Multi-Trip Annual
c 40-Day PSHCP Supplemental
c 40-Day PSHCP Supplemental
c Single Trip Daily or Top-Up Plan
c Single Trip Non-Medical Plan*
c Single Trip Daily or Top-Up Plan
c Single Trip Non-Medical Plan*
c Canada Plan
c Canada Plan
** If you are purchasing a Top-Up to an existing coverage, the Effective Date will be
** If you are purchasing a Top-Up to an existing coverage, the Effective Date will be
the day after your existing coverage terminates.
the day after your existing coverage terminates.
Name of the other Insurer: _________________________________________________ Name of the other Insurer: _________________________________________________ Number of Pre-insured days: ________________ Number of Pre-insured days: ________________ F .:Premium and Payment
For manual applications, please complete the Premium Calculation – Plans without Medical Questionaire page
to determine each Applicant’s total premium, or visit www.etfsinc.com/premiumcalculation/index.html Total Premium
$ Applicant 1
+ $ Applicant 2
Method of Payment
c Cheque made payable to the broker or sales agent indicated on the front of this application.
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Source: http://www.coveryou.ca/travel/ETFS/applyform54.pdf