Super Visa Health Insurance Request

Notice:

The Super Visa travel insurance must provide coverage of $100,000 for 365 days, in accordance with Canadian Immigration requirements.

***Installment Plan:

available only for 1 full year of coverage.

Who Is Applying?

Visitor to Canada currently in home country

Canadian Resident on behalf of a visitor

Visitor to Canada currently in Canada

Insurance Start Date *

Insurance End Date *

Number Of Days *

Arrival Date (must be on or before effective date) *

Country of Origin *

Sponsor First Name *

Sponsor Last Name *

Sponsor Location (Province) *

Will the sponsor pay the premium? *

Yes

Type Of Payment *

Visa

Mastercard

Personal Details

First Name *

Last Name *

Gender *

Male

Female

Date of birth *

Your Nationality

Address Line 1 (Canadian Address) *

Address Line 2

City *

Province *

Postal code *

Country *

Phone (Canadian Phone Number) *

Is it a cell, home, or work number?

Cell

Home

Work

Email *

Pre-existing Condition

Yes

Details of the Pre-Existing Condition *

Cover the pre-existing condition? *

Yes

Definitions

Unstable condition means a pre-existing condition for which, in the 180 days prior to your effective date of insurance, any of the following apply:

• there have been new symptoms or change in symptoms;

• existing symptoms have become more frequent or severe;

• a physician has found that the medical condition has become worse;

• test findings have shown that the medical condition may be getting worse;

• a physician has provided, prescribed, or recommended any new medication, or any change in medication;

• a physician has provided, prescribed, or recommended new treatment, or any change in treatment;

• a physician has provided, prescribed, or recommended any investigative testing, other than regular scheduled maintenance investigations or testing; • there has been hospitalization or referral to a specialist or specialty clinic;

• a physician has advised a referral to a specialist or further testing, or there has been testing for which results have not yet been received. We will not cover any heart condition if, in the 180 days before the effective date, you required any form of nitroglycerine for the relief of angina pain. We will not cover any lung condition if, in the 180 days before the effective date, you required treatment with prednisone for a lung condition.

Pre-existing Condition means sickness, illness, disease, symptom, or injury that existed or for which medication has been taken, received, or prescribed (including prescribed as needed), or for which treatment has been prescribed or received in the 180 days before your effective date of insurance as stated on your policy confirmation.

Is it stable or not? *

Stable

Not Stable

Who else do you want the policy to cover? Please enter their information below.

Additional Person - 1

Full Name of Additional Person 1

Date of Birth of Additional Person 1

Relationship 1

Gender of Additional Person 1

Male

Female

AP1: Pre-existing Condition

Yes

AP1: Details of the Pre-Existng Condition

AP1: Is it stable or not?

Stable

Not Stable

AP1: To cover the pre-existing condition?

Yes

Additional Person - 2

Full Name of Additional Person 2

Gender of Additional Person 2

Male

Female

Relationship 2

Date of Birth of Additional Person 2

AP2: Any Pre-Existing Condition, and Regular Medication?

Yes

AP2: Details of the Pre-Existing Condition

AP2: Stable or Not Stable?

Stable

Not Stable

AP2: Would you like to cover the pre-exisitng condition?

Yes

We strongly advise covering Pre-Existing condition through ENHANCED PROTECTION.

Ensuring coverage for pre-existing conditions is crucial for providing fair access to healthcare, preventing financial burdens, and promoting proactive health management. It helps improve overall health outcomes.

Coverage

Coverage Type *

Basic

Standard

Enhanced

Coverage Notes

Emergency Medical Coverage – ENHANCED (Age 55 – 85) means that this Insured has satisfied the eligibility requirements (must complete Medical Declaration Version VMD-2301) and has paid the required premium for the Enhanced Plan that includes coverage for stable pre-existing medical conditions. Coverage includes the comprehensive benefit package contained in the Enhanced Plan plus $25,000 Accidental Death & Dismemberment. All deductibles (other than the $2,500 Disappearing Deductible) apply per person per policy.

Emergency Medical Coverage - STANDARD means that this Insured has satisfied the eligibility requirements and has paid the required premium for the Standard Plan. No Medical Declaration is required but the policy does NOT include coverage for a "pre-existing condition" as defined in the policy. Coverage includes the rest of the comprehensive benefit package including $25,000 of Accidental Death & Dismemberment. All deductibles (other than the $2,500 Disappearing Deductible) apply per person per policy.

Emergency Medical Coverage - BASIC means that this Insured has satisfied the eligibility requirements and has paid the required premium for the Basic Plan. No Medical Declaration is required but the policy does NOT include coverage for any pre-existing conditions. Also NOT included with this plan are: AD&D, Dental Accident and Relief of Dental Pain. This is reduced premium, reduced benefit, basic emergency medical coverage. All deductibles (other than the $2,500 Disappearing Deductible) apply per person per claim.

Coverage Amount

$100,000

$150,000

$200,000

ELIGIBILITY (all applicants – all ages)

COVID-19 is covered like any other medical condition except 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. Be sure your client is made aware of these changes which are detailed on the Policy Confirmation. Please monitor travel.gc.ca for travel advisory updates from the Government of Canada.

ELIGIBILITY REQUIREMENTS (must select all items to be eligible) *

You are NOT travelling against the advice of a physician

You have NOT been diagnosed with a terminal illness with less than two (2) years to live

You have NOT 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 NOT or are NOT waiting for an organ or bone marrow transplant (excluding corneal transplant)

You DON'T have a kidney condition requiring dialysis

You have NOT used home oxygen during the 12 months prior to the date of application

You DO NOT reside in a nursing home, other long term care facility or rehabilitation centre; and/or

You are NOT age 86 or older (unless buying the Basic Plan)

I confirm that I meet all the eligibility requirements *

Yes

If you were not eligible for coverage on the Issue Date, no claim will be paid and the policy will be considered null and void. Contact 21 st Century or your agent immediately if you are not eligible for this insurance.

Medical Declaration (Signed, PDF Format only)

For Enhanced Coverage, and if required only

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.

If you are completing this declaration on behalf of the applicant(s) for insurance, please complete the following

Your Last Name Here

Your First Name Here

Relationship to the applicant(s)

Signature *

Clear

Personal information is being provided to 21st Century Travel Insurance Ltd. and its underwriting companies for the purpose of obtaining this insurance coverage. By submitting, I give consent in this regard.