Snowbird Travel Insurance

Have you decided to spend the winter in sunny, southern locales? Maybe you spend six months in Florida or Arizona, or perhaps travel in Costa Rica or Mexico?

Thank you for giving us chance to know you more

Please fil the below form of Medical Questionnaire for Snowbird

1

Step 1

2

Step 2

3

Step 3

4

Step 3

Have you used tobacco products in the last 24 months? (Surcharge applies)
Applicant 1
Applicant 2
Have you ever had or are you awaiting a bone marrow or organ transplant?
Applicant 1
Applicant 2
Have you ever been diagnosed with acquired immune deficiency syndrome (AIDS) or human immunodeficiency virus (HIV), amyotrophic lateral sclerosis (ALS), multiple sclerosis, myasthenia gravis, sarcoidosis any location, scleroderma, or lupus?
Applicant 1
Applicant 2
During the 3 years prior to your effective date, have you been diagnosed with or received treatment* for 3 or more of the following medical conditions?
  • - High blood pressure
  • - A stroke or mini stroke (CVA/TIA)
  • - Heart condition (including stent placement, pacemaker and/or defibrillator)
  • - Diabetes (treated with insulin or any medication)
  • - Pulmonary condition (including any prescription for puffers/inhalers) excluding a minor ailment*
  • - Narrowing or blockage of any blood vessel or peripheral vascular disease (PVD)
  • - Gastrointestinal disease/disorder excluding a minor ailment
  • - Cancer (excluding basal or squamous cell skin cancer and breast cancer treated only with hormone therapy)
Applicant 1
Applicant 2
Do you have kidney disease requiring dialysis?
Applicant 1
Applicant 2
During the 3 years prior to your effective date, have you been diagnosed with or received treatment* for 3 or more of the following medical conditions?
  • - High blood pressure
  • - A stroke or mini stroke (CVA/TIA)
  • - Heart condition (including stent placement, pacemaker and/or defibrillator)
  • - Diabetes (treated with insulin or any medication)
  • - Pulmonary condition (including any prescription for puffers/inhalers) excluding a minor ailment*
  • - Narrowing or blockage of any blood vessel or peripheral vascular disease (PVD)
  • - Gastrointestinal disease/disorder excluding a minor ailment
  • - Cancer (excluding basal or squamous cell skin cancer and breast cancer treated only with hormone therapy)
Applicant 1
Applicant 2
During the 3 years prior to the effective date have you been diagnosed with stage III or stage IV cancer or cancer that has metastasized?
Applicant 1
Applicant 2
During the 3 years prior to the effective date have you been diagnosed with or received treatment* for any of the following medical conditions?
  • - COPD (chronic obstructive pulmonary disease), emphysema or chronic bronchitis?
  • - a stroke or mini-stroke (CVA /TIA)?
  • - Diabetes treated with insulin?
  • - Alzheimer's or dementia?
Applicant 1
Applicant 2
Was your most recent heart surgery (heart bypass, heart angioplasty (including stent placement) or heart valve surgery or implanted pacemaker (excluding batter replacement) more than 10 years prior to your effective date?
Applicant 1
Applicant 2
During the 3 years prior to the effective date have you been diagnosed with or received treatment* for narrowing or blockage of any blood vessel including peripheral vascular disease (PVD), aneurysm, atherosclerosis, blood clots, carotid artery stenosis or thrombophlebitis, excluding varicose veins.
Applicant 1
Applicant 2
During the 3 years prior to your effective date have you been diagnosed with or received treatment* for any of the following medical conditions:
  • - a) Cancer (excluding basal or squamous cell skin cancer or breast cancer treated only with hormone therapy)?
  • - b) Bowel obstruction or bowel surgery?
  • - c) Inflammatory bowel disease, gastrointestinal bleeding, Crohn's disease, colitis or diverticulitis or diverticulosis or GERD (gastroesophageal reflux disease)?
  • - d) Diabetes treated with medication other than insulin?
  • - e) Gallbladder disease (including stones)?Note: If your gallbladders has been removed, answer NO.
  • - f) Kidney disease (including stones)?
  • - g) Liver disease?
  • - h) Pancreatic disease?
  • - i) Pulmonary condition (including asthma and pneumonia or conditions for which medical treatment or a prescription was required) excluding a minor ailment?
Applicant 1
Applicant 2
During the 12 months prior to your effective date have you been treated for or diagnosed with a Urinary Tract Infection (UTI) or Prostate disorder (other than cancer)?
Applicant 1
Applicant 2
During the 12 months prior to your effective date have you been treated with 3 or more medications at the same time for high blood pressure?
Applicant 1
Applicant 2
During the 12 months before your effective date have you had an episode of syncope or fainting or sought medical treatment* for a fall?
Applicant 1
Applicant 2
During the 12 months prior to the effective date have you been diagnosed with or received treatment* for high blood pressure or high Cholesterol?
Applicant 1
Applicant 2
On your effective date will it have been more than 24 months since your last medical examination with a physician? For the purpose of this question a medical examination means a medical examination performed for the purpose of general health screening or monitoring, which may include routine medical tests and which is unrelated to any specific symptom, illness, condition or disease.
Applicant 1
Applicant 2