SuperVisa Questionnaire Form

Super Visa Insurance Questionnaire Form
Name of Insured(s):

First NameLast Name
Date of Birth

MonthDayYear
Date
#2 Name of Insured(s):

First NameLast Name
Date of Birth

MonthDayYear
Date
#3 Name of Insured(s):

First NameLast Name
Date of Birth

MonthDayYear
Date
#4 Name of Insured(s):

First NameLast Name
Date of Birth

MonthDayYear
Date
Home Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Phone Number
Format: (000) 000-0000.
E-mail
example@example.com
Start Date of Coverage

MonthDayYear
Date
End Date of Coverage

MonthDayYear
Date
Arrival Date in Canada

MonthDayYear
Date
Coverage Limit
Deductible Options
Beneficiary?
Please enter the name of the beneficiary
Any claims in the past 5 years?
If yes, you had a claim, please explain?
Previous/Current Policy Number? (if applicable)
Have you been advised against travel by a physician?
Do you have surgically untreated aneurysm?
Do you or have you ever had?
Do you currently reside in a nursing home, assisted living home, convalescent home, hospice or rehabilitation centre?
Do you require assistance with normal daily activities?
Have you taken (or been prescribed) oral steroids or used home oxygen to treat a lung condition in the 12 months before your policy start date?
Please check each condition you have been diagnosed with or treated for in the 12 months before your start date:
Do 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.
Please upload old policy for reference (if applicable)

Cancelof
Will you be willing to recommend me?

Please give reference of any two people whom you feel:

Rows	Full Name	Address	Contact Number
1
2

Should be Empty:

Super Visa Insurance Questionnaire Form