Travel Insurance - PDF document

1 TuGo ™ Travel Insurance Quest F
TuGo ™ Travel Insurance Quest For travellers 55 + World-class pre-existing condition coverage What if I have an unstable pre-existing condition? If you’re not sure if your pre-existing condition is (or will be) stable before you leave for your trip, don’t worry. TuGo oers Guaranteed and Future Stability Options with coverage up to $150,000. We’re one of the only companies that provides this peace of mind. Your health shouldn’t prevent you from getting the best travel insurance. Talk to your broker today! Guaranteed Stability Option Choose Guaranteed Stability Option coverage if your pre-existing condition hasn’t been stable for the required amount of time (90/180/365 days) and you’ll be covered up to $150,000 for that condition. Future Stability Option If your pre-existing condition is stable—but you don’t want to worry about it becoming unstable before leaving on your trip—our Future Stability Option is right for you! Get protection based on your condition being stable at the time of application so you’re guaranteed up to $150,000 in coverage for your unstable pre-existing medical conditions. How can I save money? Deductible options: If you want a discount on your premium you can increase your deductible to a maximum of $100,000 USD. Get the coverage you need at the price you want! Where to next? Planning to sip a smoothie on a tropical beach while reading your favourite book? Or driving your RV south to avoid the Canadian winter? Maybe you’re taking the grandkids to Europe or heading to Africa for the safari of a lifetime. Whatever your dreams, don’t let medical costs hold you back. If you get sick or injured away from home, TuGo ™ will take care of you. We do more than just pay the bills. The TuGo team coordinates with medical sta to get you the best treatment, wherever you are in the world. Just call us! We’re here for you. 24/7 emergency assistance Multilingual Customer Service team Over 50 years of building relationships with healthcare providers all over the world What if I have a pre-existing medical condition? No problem. Many senior travellers have diabetes, heart conditions or other medical concerns. Fill out TuGo’s simple Quest Medical Health Questionnaire to nd out which plan you qualify for. What is a stability period? A stability period is the length of time your pre-existing medical condition has to be “stable” before your trip. You’re stable as long as your medications haven’t changed and your condition hasn’t worsened within the stability period of the plan you qualify for. Fill out our Medical Health Questionnaire to nd out which of the

2 following rates you qualify for and wha
following rates you qualify for and what pre-existing stability requirement applies: GOLD RATE 90 day stability period SILVER RATE 180 day stability period BRONZE RATE 180 day stability period* *365 day stability period for diabetes, heart and lung conditions Deductible $USD Discount $0 0% (Automatic) $300 -10% $500 -15% $1,000 -20% $5,000 -35% $10,000 -40% $50,000 -55% $100,000 -70% Companion Discount: Travelling with someone? A 5% companion discount may be available to you. Review the following questions to nd out if you are eligible for Quest Travel Insurance. If you or your travelling companions are not eligible, please ask your broker about alternate coverage from TuGo. Complete the Medical Health Questionnaire by placing a check mark in the Yes or No box next to each question. If you are unsure about how to answer any of these questions, please consult your regular physician. Once the questionnaire is complete, please review and provide a signature for each applicant. Eligibility Medical Health Questionnaire APPLICANT 1 APPLICANT 2 If you answered Yes to any of the eligibility questions listed above, you are not eligible to purchase this insurance. If you answered No to all the eligibility questions above you must initial the box below before proceeding to the plan/rate qualication section. To be eligible to purchase this insurance, you must be 55 to 89 years of age and must answer No to all of the following questions. 1. In the 36 months prior to application have you been diagnosed with, treated or ordered by a physician to take medication for, three (3) or more of the following medical conditions? Heart disease/condition Liver disease/condition Lung disease/condition (excluding asthma not requiring prednisone) Diabetes (requiring medication) Stroke or mini-stroke (TIA or transient ischemic attack) 2. In the 12 months prior to application, have you been diagnosed with, treated or been ordered by a physician to take medication for peripheral vascular disease (blocked leg arteries); congestive heart failure; chronic obstructive pulmonary disease (COPD, emphysema)? 3. In the 12 months prior to application, have you used or been prescribed home oxygen? 4. Do you have a terminal condition or metastatic cancer? 5. Did you have heart bypass surgery more than 10 years before application? (Answer “no” to this question if you have had additional bypass surgery and/or placement of a stent less than 10 years prior to application) 6. Have you had an organ transplant (excluding cornea or skin gra)? 7. Do you have a kidney disease requiring kidney dialysis? 8. Do you have an aneurysm larger than four (4) centimetres, measured in either length or diameter? 9. In the

3 6 months prior to application have you h
6 months prior to application have you had a stroke or mini-stroke (TIA or transient ischemic attack)? PLAN/RATE QUALIFICATION APPLICANT 1 APPLICANT 2 10. In the 5 years prior to application have you been diagnosed with, treated or ordered by a physician to take medication or been hospitalized for any of the following: Yes No Yes No Heart attack, aneurysm, angioplasty, atrial brillation, artery bypass surgery, cardiac surgery, angina, irregular heartbeat, pacemaker, thrombosis, phlebitis, pulmonary edema Chronic asthma, chronic bronchitis or pneumonia Yes No Yes No Diabetes (requiring medication) Yes No Yes No Stroke or mini-stroke (TIA or transient ischemic attack) Yes No Yes No Carotid artery stenosis (blocked or clogged arteries in the neck) Yes No Yes No Liver disease/condition Yes No Yes No Cancer (excluding basal cell skin cancer) Yes No Yes No Kidney disease that required dialysis, now no longer on dialysis Yes No Yes No If you answered Yes to any of the conditions/events listed in question 10, you qualify for the Bronze plan. Proceed to question 16. If you answered No , proceed to question 11. PLAN/RATE QUALIFICATION APPLICANT 1 APPLICANT 2 15. Have you had a fall that you reported to a physician in the last 6 months? Yes No Yes No If you answered Yes to questions 13, 14 or 15 you qualify for the Silver plan. Proceed to question 16. If you answered No to questions 13, 14 and 15 you qualify for the Gold plan. Proceed to question 16. 16. In the 12 months prior to application, have you smoked tobacco products? Yes No Yes No *Certain terms are dened in this brochure; please refer to the list of denitions. PLAN/RATE QUALIFICATION APPLICANT 1 APPLICANT 2 11. In the 24 months prior to application, how many of the following medical conditions have you been diagnosed with, treated for or ordered by a physician to take medication for? Yes No Yes No Kidney disease Gastrointestinal bleeding Yes No Yes No Alzheimer’s disease/dementia Yes No Yes No Pancreatitis Yes No Yes No Chronic bowel disease Yes No Yes No Bowel obstruction Yes No Yes No If you have TWO or MORE of the conditions listed in question 11, you qualify for the Bronze plan. Proceed to question 16. If you have ONE of the conditions listed in question 11, you qualify for the Silver plan. Proceed to question 16. If you have NONE of the conditions listed in question 11, proceed to question 12. 12. In the 12 months prior to application, have you been diagnosed with or undergone change in medical treatment (including an alteration in medication dosage or usage) for high blood pressure AND had any of the following conditions? Yes No Yes No Hig

4 h cholesterol Diabetes (not requiring me
h cholesterol Diabetes (not requiring medication) Yes No Yes No Gallbladder disease Yes No Yes No Osteoporosis Yes No Yes No Arthritis Yes No Yes No If you answered Yes to high blood pressure AND any other conditions listed in question 12, you qualify for the Silver plan. Proceed to question 16. If you answered No to question 12, proceed to question 13. 13. Have you ever been treated for a heart disease/condition (excluding congenital heart disease)? Yes No Yes No 14. Was your last regular check-up with a physician more than 24 months ago? Yes No Yes No Please read and sign If you have any doubt about your medical condition(s) as it relates to the previous questions, you should consult your physician for advice before completing this Medical Health Questionnaire. If you do not answer questions 1-9 truthfully and accurately, the coverage will be void. If you qualify for the coverage selected but fail to answer questions 10-16 truthfully and accurately, any claim will be subject to an extra deductible of $15,000 USD in addition to any other applicable deductible amount. Questions you did not need to answer during the application process will not be subject to this extra deductible. No future coverage will be provided under this policy unless you pay an additional premium reecting true and accurate answers to those questions. I understand that the medical conditions disclosed on this application may not be covered. Details related to pre-existing conditions coverage are set out in the Policy booklet. I/We conrm that I/We have answered this Medical Health Questionnaire truthfully and accurately as it relates to my/our health conditions. SIGNATURE Applicant 1 SIGNATURE Applicant 2 Date X X Please provide the following details about yourself and your travel plans. The following denitions are for general information only. Applicants are advised to consult their physician for more detailed information about medical conditions that may aect them. Personal & Travel Information Applicant 1 Name Date of Birth Male Female Applicant 2 Name Date of Birth Male Female Canadian Street address (Applicants living in separate households should ll out separate applications) Address Phone Number Email address Travel Plans Date of Departure Scheduled Return Date Total Trip Days Are you topping up another policy? Yes No Number of days covered under other insurance Name of plan DD | MM | YYYY DD | MM | YYYY Medical Denitions Alteration —Includes an increase or decrease in medication dosage, usage or a change in medication type, but does not include changes in brand due solely to t

5 he availability of your usual brand or
he availability of your usual brand or due to government regulations regarding reference-based pricing. Alzheimer’s disease —A form of dementia, it is a progressive, degenerative brain disease. It aects memory, thinking, and behavior. Aneurysm —A localized widening (dilatation) of an artery, vein, or the heart. At the area of an aneurysm, there is typically a bulge and the wall is weakened and may rupture. Angina —Chest pain due to coronary artery spasm, a sudden constriction of a coronary artery depriving the heart muscle of blood and oxygen. Angioplasty —Procedure with a balloon-tipped catheter to enlarge a narrowing in a coronary artery. Sometimes a “stent”, or bridge, is inserted to keep the artery open. Arthritis —Inammation of a joint. When joints are inamed they can develop stiness, warmth, swelling, redness and pain. Atrial brillation —Abnormal irregular heart rhythm with chaotic generation of electrical signals in the atria of the heart. Sometimes requires anticoagulation (blood thinners such as Coumadin / warfarin). Bowel obstruction —Bowel obstruction is a mechanical blockage of the intestines, preventing the normal transit of products of digestion. Cancer —(except basal cell skin cancer) Any malignant growth or tumor caused by abnormal and uncontrolled cell division; it may spread to other parts of the body through the lymphatic system or the blood stream. Carotid artery stenosis —A narrowing of a carotid artery in the neck. Chronic asthma —Asthma (wheezing and cough) requiring maintenance treatment to achieve part or total control. Chronic bowel disease —Chronic inammation of the bowels with diarrhea, cramps, and sometimes bleeding. Chronic bronchitis —An inammation of the main airways in the lungs that continues for a long period or keeps coming back. Chronic obstructive pulmonary disease (COPD) —Lung disease that makes it dicult to breathe, caused by smoking, chronic asthma etc. also called emphysema. Congenital heart disease —A malformation, present at birth, of the heart or the large blood vessels near the heart. Congestive heart failure —Inability of the heart to keep up with the demands on it and, specically, failure of the heart to pump blood with normal eciency due to chronic heart disease. Causes uid in the lungs, shortness of breath, decreased exercise tolerance. Dementia —Signicant loss of intellectual abilities such as memory capacity, severe enough to interfere with social or occupational functioning. Diabetes —A chronic condition where the body is unable to produce insulin and prop

6 erly regulate or maintain sugar (gluc
erly regulate or maintain sugar (glucose) level in the blood. Includes Type 1 diabetes mellitus, (insulin dependent or juvenile type) and Type 2 diabetes (adult-onset or non insulindependent diabetes mellitus-NIDDM), which is the most common form of diabetes. Emphysema —See chronic obstructive pulmonary disease (COPD). Gallbladder disease —Includes inammation, infection, stones, or obstruction of the gallbladder—causes right upper abdominal pain. Gastrointestinal bleeding —Refers to any bleeding that starts in the gastrointestinal tract, which extends from the mouth to the large bowel. The amount of bleeding can range from nearly undetectable to acute, massive, and life threatening. Bleeding may come from any site along the gastrointestinal tract, but is oen divided into Upper GI bleeding and Lower GI bleeding. Heart disease/condition —An abnormal condition of the heart, heart disease or cardiopathy. High blood pressure —Also known as hypertension. For example, blood pressure above 140/90 for more than 6 months. High cholesterol —Elevated fat content in blood. Irregular heartbeat/palpitations —Feels like the heart is pounding or racing. You may simply have an unpleasant awareness of your own heartbeat, or may feel skipped or stopped beats. The heart’s rhythm may be normal or abnormal. Palpitations can be felt in your chest, throat, or neck. Kidney dialysis —Medical treatment replaces the function of the kidneys, which normally serve as the body’s natural ltration system. Kidney disease —Any disease or disorder that aects the function of the kidneys. Liver disease/condition —The term “liver disease” applies to many diseases and disorders that cause the liver to function improperly or cease functioning. Abnormal results of liver function tests oen suggest liver disease. Lung disease/condition —Any abnormal condition of the lungs, aecting the lungs or associated airways. Most commonly applicable to lung infection such as pneumonia, Chronic Obstructive Pulmonary Disease (COPD), bronchial asthma, etc. Medication(s) —Includes medication that requires a prescription from a physician or other registered medical practitioner and medication purchased over the counter as per the physician’s advice or other registered medical practitioner’s advice, not including aspirin taken for preventative reasons. Metastatic cancer —Cancer that has spread from the place in which it started to other parts of the body. Osteoporosis —Thinning of bone tissue and loss of bone density over time making fractures more likely. Pancreatitis —An inammation or infection of

7 the pancreas. Peripheral vascular dise
the pancreas. Peripheral vascular disease (blocked leg arteries) — Also known as Arteriosclerosis of the extremities is a disease of the blood vessels characterized by narrowing and hardening of the arteries that supply the legs and feet. This causes a decrease in blood ow that can cause painful legs and injure nerves and other tissues. Phlebitis —Also known as thrombophlebitis; the swelling (inammation) of a vein caused by a blood clot. Pneumonia —An infection of the lungs. Pulmonary edema —An abnormal build up of uid in the lungs, which leads to swelling. Associated with congestive heart failure. Stroke or mini-stroke (TIA or transient ischemic attack) —An interruption of the blood supply to any part of the brain. A stroke is sometimes called a “brain attack”. Terminal condition —A medical condition for which, prior to the commencement date of the covered trip, a physician has given you a terminal prognosis with a life expectancy of 12 months or less. Tobacco products —Not a medical term. Examples are cigarettes, cigars, cigarillos, pipe. Marijuana comes under the class of “drug” or “substance”. Thrombosis —The formation or presence of a blood clot in a blood vessel. Contact Broker Please provide quote for: Annual Travel Medical: 9 day 16 day 30 day 60 day Trip Cancellation/Interruption (sum insured per person) Single Trip Travel Medical Future Stability Option Guaranteed** Stability Option ** The language in this document may not be the same as the actual policy wording which will prevail in all instances and is available upon request. Certain exclusions, limitations and conditions may apply. Call or visit your insurance broker. Your broker will make sure you get the right coverage for your needs. tugo.com The language in this document may not be the same as the actual policy wording which will prevail in all instances and is available upon request. Certain exclusions, limitations and conditions may apply. TuGo is a registered trademark of and is administered by North American Air Travel Insurance Agents Ltd. d.b.a. TuGo, a licensed insurance broker in British Columbia, Alberta, Saskatchewan, Manitoba, and Ontario, represented by licensed insurance agents Kathleen S. Starko and Bradley G. Dance in New Brunswick, Nova Scotia and P.E.I. 11th Floor - 6081 No. 3 Road, Richmond, BC Canada V6Y 2B2. Insurance is underwritten by Industrial Alliance Insurance and Financial Services Inc. and certain Lloyd’s Underwriters, severally and not jointly. quest_br_2015-05 Get your coverage quickly and easily. Ask your broker today about TuGo Travel Insurance, so you’re protected wherever you go