Visitor Visa Insurance Form

Super Visa/Visitor Visa Insurance Form

Please fill the form accurately for better assistance
Insurance Company*
One PersonTwo PersonsThree PersonsFour PersonsFive Persons

Person 1 Full Name*

First NameLast Name
MaleFemale
YesNo
Date of Birth*

DayMonthYear
Date
List Medical Conditions Here*

Person 2 Full Name*

First NameLast Name
MaleFemale
YesNo
Date of Birth*

DayMonthYear
Date
List Medical Conditions Here*

Expected Arrival Date in Canada*

DayMonthYear
Date
Return Date From Canada*

DayMonthYear
Date
Phone Number*
Format: 000-000-0000.
E-mail*
example@example.com
Canadian Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Emergency Contact Name*
Phone Number*
Format: (000) 000-0000.

Beneficiary Name*

First NameLast Name
Relationship with Insured Person*
Coverage Amount*
Note- Supervisa Insurance is mandatory to have coverage amount at least $100,000 and minimum duration for 365 days.
Permanent ResidentCanadian CitizenVisitor to CanadaWork PermitOther

YesNo
YesNo
YesNo
YesNo
Do they have or have they ever had- (Person-1)
- Pancreatic or liver cancer, or any type of metastasized cancer
- A kidney condition requiring dialysis
- Congestive Heart Failure
- A Bone Marrow or Organ Transplant
- A Terminal Sickness
YesNo
Do they have or have they ever had- (Person-2)
- Pancreatic or liver cancer, or any type of metastasized cancer
- A kidney condition requiring dialysis
- Congestive Heart Failure
- A Bone Marrow or Organ Transplant
- A Terminal Sickness
YesNo
YesNo
YesNo
YesNo
YesNo
YesNo
YesNo

YesNo
YesNo
Please communicate the following declaration to the applicant(s):

You declare that the information given is accurate. If you were unsure about the medical information needed for a question you have checked with your doctor.

You understand that if you have provided incorrect information Old Republic Insurance Company of Canada will void the policy and cancel all coverage.

You also understand that if your health changes before Your Start Date you must contact your broker to update your eligibility.

To be eligible for coverage, on the effective date, you must:
1. be a visitor to Canada or a person in Canada under a valid work or student visa, a Canadian or an immigrant not eligible for benefits under a government health insurance plan; and
2. be at least 15 days of age and less than 90 years of age; and
3. not be travelling against the advice of a physician and/or have not been diagnosed with a terminal illness; and
4. not be experiencing new or undiagnosed signs or symptoms and/or know of any reason to seek medical attention; and
5. not require assistance with the activities of daily living (eating, bathing, dressing, functional mobility, using the toilet).
Waiting Period:

If you purchase this coverage after your arrival in Canada there is no coverage for any sickness that began, or for which you experienced symptoms, during:
1. the 48-hour period following the effective date of the policy if insurance is purchased within 30 days of your arrival to Canada; or
2. the 8-day period following the effective date of the policy if insurance is purchased more than 30 days after your arrival to Canada,
even if related expenses are incurred after the Waiting Period.

Exception:

The waiting period may be waived if this policy is purchased on or prior to the expiry date of an existing Secure Travel RIMI Visitors to Canada Travel Insurance policy already issued by the insurer, to take effect on the day following such expiry date provided no increase in the sum insured option is applied for. The existing policy must be in effect on the date of purchase and there must be no gap in coverage.
Please communicate the following declaration to the applicant(s):

You declare that the information given is accurate. If you were unsure about the medical information needed for a question you have checked with your doctor.

You also understand that if your health changes before Your Start Date you must contact your broker to update your eligibility.

Coverage is NOT AVAILABLE to any individual who:
- has been diagnosed with a terminal illness; or
- has been diagnosed with or received treatment for pancreatic cancer, liver cancer, or any type of cancer that has metastasized (migrated to another organ from its original site); or
- has been prescribed or used home oxygen in the last 12 months; or
- has been diagnosed with or received treatment for congestive heart failure; or
- has had a major organ transplant (heart, kidney, liver, lung); or
- has received kidney dialysis treatment in the last 12 months.
To be eligible for coverage you must, as of the effective date:
- be at least 15 days old, and
- be in good health at the time you purchase your policy and on the effective date, and know of no reason why you would seek medical attention during the period of coverage.
- not be insured or eligible for benefits under a Canadian Government Health Insurance Plan (GHIP).
Waiting Period:
- Age 0 to 85
  - If the insurance was purchased prior to your arrival date in Canada, the “waiting period” does not apply or,
  - If this insurance is purchased any time after your arrival in Canada, then in respect of any sickness you will only be entitled to receive benefits for the cost of eligible medical expenses incurred after the first 48 hours from the effective date of the policy.
- Age 86 and over
  - If the insurance was purchased prior to the arrival date in Canada, the “waiting period” does not apply.
  - If the insurance is purchased after your arrival date in Canada, then in respect of any sickness you will only be entitled to receive benefits for the cost of eligible medical expenses incurred after fifteen (15) days from the effective date of this policy.
- The waiting period may be waived if:
  - This policy is purchased on or prior to the expiry date of an existing Destination: Canada policy.
  - If you have insurance with another insurer during the first part of your trip in Canada, and you are purchasing this insurance after your arrival in Canada and there will be no gap in coverage. You must provide satisfactory proof that you have other coverage in force and receive written approval from the Insurer.
Please communicate the following declaration to the applicant(s):

You declare that the information given is accurate. If you were unsure about the medical information needed for a question you have checked with your doctor.

You also understand that if your health changes before Your Start Date you must contact your broker to update your eligibility.

There is no coverage for medical expenses resulting from COVID-19 and related conditions while on a Side-Trip outside of Canada if a Government of Canada Level 3 (avoid non-essential travel) or Level 4 (avoid all travel) travel advisory related to Covid-19 is in effect for you or for the destination on the day they leave Canada.

Please monitor travel.gc.ca for travel advisory updates from the Government of Canada.

You are not eligible for coverage under this policy if:

• you are traveling against the advice of a physician;
• you have been diagnosed with a terminal illness with less than two (2) years to live;
• you have been diagnosed with or received treatment within the last two (2) years for pancreatic, lung, brain, or liver cancer; or any type of cancer that has spread from one part or organ of the body to another (metastatic cancer);
• you have had or are waiting for an organ or bone marrow transplant (excluding corneal transplant);
• you have a kidney condition requiring dialysis;
• you have used home oxygen during the 12 months prior to the date of application;
• you reside in a nursing home, other long term care facility or rehabilitation centre; and/or
• You are age 86 or older (unless buying the Basic Plan)

Medical Questions - (Person-1)

Rows	Yes	No
1. In relation to any heart or lung condition, shortness of breath, chest pain, stroke or mini-stroke (Transient Ischemic Attack/TIA), have you within the last 12 months: a) been newly diagnosed, b) been prescribed any new medication or any change in dosage, frequency or type of medication, c) had any new or any change in treatment (including investigation or testing), d) been referred to a specialist physician for investigation or testing, or e) been hospitalized or been seen in the emergency department of a hospital?
2. Have you: a) had a heart bypass, heart valve surgery or angioplasty more than 10 years ago (use the date of the most recent procedure), or b) been diagnosed with a heart valve disorder but not yet had heart valve surgery?
3. Have you ever been diagnosed with congestive heart failure?
4. Within the past 12 months have you: a) been treated for and/or been diagnosed with internal bleeding; or b) been admitted to hospital for a gastrointestinal disease or disorder; or c) received treatment (including investigation or testing) for any cancer (except basal cell and squamous cell skin cancer)?
5. 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 (answer No if you are medicated for one but not both of these conditions. Medication prescribed solely for the control of blood pressure is not a medication for a heart condition; d) any form of nitroglycerin for the relief of angina pain (including on an “as needed” basis)?

Medical Questions - (Person-2)

Rows	Yes	No
1. In relation to any heart or lung condition, shortness of breath, chest pain, stroke or mini-stroke (Transient Ischemic Attack/TIA), have you within the last 12 months: a) been newly diagnosed, b) been prescribed any new medication or any change in dosage, frequency or type of medication, c) had any new or any change in treatment (including investigation or testing), d) been referred to a specialist physician for investigation or testing, or e) been hospitalized or been seen in the emergency department of a hospital?
2. Have you: a) had a heart bypass, heart valve surgery or angioplasty more than 10 years ago (use the date of the most recent procedure), or b) been diagnosed with a heart valve disorder but not yet had heart valve surgery?
3. Have you ever been diagnosed with congestive heart failure?
4. Within the past 12 months have you: a) been treated for and/or been diagnosed with internal bleeding; or b) been admitted to hospital for a gastrointestinal disease or disorder; or c) received treatment (including investigation or testing) for any cancer (except basal cell and squamous cell skin cancer)?
5. 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 (answer No if you are medicated for one but not both of these conditions. Medication prescribed solely for the control of blood pressure is not a medication for a heart condition; d) any form of nitroglycerin for the relief of angina pain (including on an “as needed” basis)?

Please communicate the following declaration to the applicant(s):

You declare that the information given is accurate. If you were unsure about the medical information needed for a question you have checked with your doctor.

You also understand that if your health changes before Your Start Date you must contact your broker to update your eligibility.

Declaration.
- I/we certify that the information provided on this form is true and accurate, and understand that such information is material to the risk, and constitutes the basis of coverage offered.
- I/we fully understand that if any of my/our answers are untrue or incorrect, then coverage offered will be null and void.
- I/we understand that the policy contains important terms and conditions of coverage including exclusions and other limitations.
- I/we understand that Manulife, its agents, third party administrators or its legal representatives may investigate a claim.
- I/we authorize any hospital, physician, or their medical service provider, or any other organization or person that has any records or knowledge of me/us and my/our health to release to third party administrators, and Manulife and its reinsurers, any such information for the purpose of this application, contract and subsequent claim.

I am Eligible
I am Eligible
You have answered Yes to one of the Eligibility Questions; and to proceed further,

Submit the form and give me a call at-

416-896-5678
Should be Empty:

Rows	Yes	No
Coronary Artery Disease, (including heart attack or angina)
Valvular heart disease (including stenosis, regurgitation or valve replacement)
Heart arrhythmia (including atrial flutter, atrial fibrillation, ventricular fibrillation or use of a pacemaker)
A lung or respiratory condition for which daily medication has been prescribed (including inhalers)
Diabetes requiring insulin
Stroke or mini-stroke (TIA)
Aneurysm
Blood clots
Gastro-intestinal bleed

Rows	Yes	No
Coronary Artery Disease, (including heart attack or angina)
Valvular heart disease (including stenosis, regurgitation or valve replacement)
Heart arrhythmia (including atrial flutter, atrial fibrillation, ventricular fibrillation or use of a pacemaker)
A lung or respiratory condition for which daily medication has been prescribed (including inhalers)
Diabetes requiring insulin
Stroke or mini-stroke (TIA)
Aneurysm
Blood clots
Gastro-intestinal bleed

Super Visa/Visitor Visa Insurance Form