664 Main St oakbank@obstax.

com
Box 515
Oakbank, Mb. R0E 1J0
(204) 444-5678 www.obstax.com

Travel Insurance
Questionnaire
People Travelling
Smoker or
Name Date of Birth Non-smoker

_________________________________ _____________________ S / NS

_________________________________ _____________________ S / NS

_________________________________ _____________________ S / NS

_________________________________ _____________________ S / NS

_________________________________ _____________________ S / NS

Date of Departure: _______________________________

Date of Return: _______________________________

Where are your headed: _______________________________

What Type of Coverage are you looking for?

Trip Cancellation? Yes / No (If yes, please bring in your booking receipt)

Loss of Baggage? Yes / No

Travel Medical? Yes / No

Do you have existing coverage through work or an annual plan? Yes / No

If yes, Who is it through? __________________________

How many days are you covered? _____________
If possible, please bring in a copy of your coverage.

In event of a claim, please be prepared to submit documentation to prove departure and return dates. Examples
including airline tickets or itineraries, gas receipts and hotel receipts.

I:\Templates\Insurance\Travel Insurance Questionnaire.docx

You may not be eligible for emergency medical care if you have any of the following (Please discuss with your Advisor):

- Implantable Cardioverter Defibrillator

- You have been diagnosed with congestive heart failure
- You are awaiting further tests or treatment for heart disease
- You require insulin and also take a prescription drug for heart disease
- You have been diagnosed with metastatic cancer
- You have cancer (except for breast or prostate cancer treated exclusively with hormonal therapy or basal cell
carcinoma) which requires chemotherapy, radiotherapy or other medical treatment other than routine follow
up
- You have any vascular aneurysm that remains surgically untreated
- You are over 70 years if age and require assistance from another person with activities of daily living (ie.
Personal hygiene, grooming, dressing and undressing, self feeding, functional transfers, bowel and bladder
management, and or medication management)
- You need home oxygen
- Within 12 months prior to applying you have been diagnosed with any of the following conditions which have
not been stable for 12 months prior to applying
o AIDS
o Terminal illness
o Atrial Flutter
o Atrial / ventricular fibrillation
o Peripheral vascular disease
o Blood clot(s)
o Gastrointestinal bleeding
o Kidney / Liver failure
- Within 12 months of applying you have undergone any of the following:
o Kidney dialysis
o Valve Surgery or replacement
o Organ, stem cell and/or bone marrow transplant

Medical conditions which are not stable for 180 days prior to your departure will not be covered under
Emergency Medical. (Ask your advisor for actual policy wordings if you are not sure).

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