Detailed medical questionnaire Underwritten by Co-operators Life Insurance Company.

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canadian expatriates visitors to canada inpatriates to canada Detailed medical questionnaire Underwritten by Co-operators Life Insurance Company. How to complete this form: Complete one form for each person applying for insurance. Answer all questions on the form. For the complete terms, conditions, limitations and exclusions If you re unsure about your answers, please talk to your please refer to the policy. physician first. Mail, fax or email it back to us Applicant, legal guardian or power of attorney must sign and TIC Travel Insurance Coordinators Ltd. date the form. Underwriting Department If you have any questions about this form, you can reach us 2100 250 Yonge Street, Toronto toll-free at: 1-888-298-8151. Ontario M5B 2L7 If your application is missing information or isn t signed and Fax: 1-866-256-2377 or 416-340-0790 dated, we ll have to follow up with you or your agent/broker and it will take longer to process your application. Email: directuw@travelinsurance.ca Eligibility 1. Coverage is T AVAILABLE to any individual who, as of their departure date: a) has been diagnosed with a terminal illness; or b) has been diagnosed with or has had an episode of congestive heart failure; or c) has had their most recent heart surgery more than 10 years ago; or d) has been diagnosed with Acquired Immune Deficiency Syndrome (AIDS) or Human Immunodeficiency Virus (HIV); or e) has been diagnosed with stage 3 or 4 cancer, or cancer of the lung, liver, pancreas, or bone; or has received treatment for any cancer (other than basal or squamous cell skin cancer or breast cancer treated only with hormone therapy) in the past 3 months; or f) has had a lung condition for which, in the last 12 months, they have been prescribed or used home oxygen; or g) has received or is awaiting a bone marrow or major organ transplant; or h) has been diagnosed with or received treatment for kidney disease requiring dialysis; or i) has been diagnosed with an aneurysm that has not been repaired; or j) requires assistance with activities of daily living. You are eligible to apply for coverage if you meet the eligibility requirements stated. Do you confirm that you are eligible to apply? YES Information about you Last name (please print) First name of birth male female Previous TIC policy # s (if known) Street Apt # City Province Postal code Phone Fax E-mail Information about your agent Only complete this section if you have an agent Who should we contact? you your agent Agent s name Send correspondence by Agent s code Fax E-mail Attention Page 1 of 5 Ready to begin? Please go to the next page to get started.

Details about your travel plans Destination (city, state or country) Departure date Return date What type of coverage do you want? Visitors to Canada Plan Canadian Expatriates Plan Inpatriates to Canada Plan $10,000 $100,000 Standard $100,000 Non-USA/Mexico $100,000 $25,000 $150,000 Enhanced $500,000 Worldwide $150,000 $50,000 Deluxe $2,000,000 Occupation: $200,000 Your medical Information Height ft/ in cm Weight lbs kg 1. Have you smoked or used any tobacco products in the last 5 years? YES 2. When was the last visit to your physician or medical clinic? (mm/dd/yyyy) Reason for visit/results (diagnosis, medications prescribed, follow-up appointments, investigations or treatments, surgery recommended or scheduled) 3. Have you been advised by a physician to have a test, investigation or surgery that you haven t had yet? YES please provide details Your medical conditions Check YES or for each group of conditions Check YES if you ve ever had symptoms, investigations or treatment for any of the conditions in the group, then check the box beside the specific condition you have. If you have more than one condition, check the box for every condition that you have. Auto-immune disorder Lou Gehrig s disease Blood disorder idiopathic thrombocytopenic purpura (ITP) scleroderma acquired immune deficiency (AIDS) or human immunodeficiency virus (HIV) multiple sclerosis hemochromatosis sickle-cell anemia anemia thrombophilia (hypercoagulability) systematic lupus erythematosis sarcoidosis any location myasthenia gravis hemophilia (hypocoagulability) spleen removed High blood pressure, cholesterol or water retention high blood pressure not taking medication taking medication medications high cholesterol not taking medication taking medication medications treated for water retention or edema in the last 12 months Please continue to the next page to tell us about symptoms, investigations and treatments. Page 2 of 5

Diabetes Blood Vessels pre-diabetes diet-controlled diabetes aneurysm repaired? YES location: abdominal brain thoracic heart Lung Condition chronic obstructive pulmonary disease (COPD) emphysema Heart cardiomyopathy chest pain or angina prescribed and/or used any form of nitroglycerin (spray, patch, pill) heart attack cardiac or heart surgery type 1 diabetes (insulin) type 2 diabetes (oral medication) chronic kidney failure diabetic neuropathy skin infection (in last 30 days) atherosclerosis angina phlebitis (vein inflammation) peripheral vascular disease (PVD) deep vein thrombosis (DVT) thrombophlebitis asthma no medication prednisone inhaler bronchitis 3 or more episodes in last 24 months What type of surgery? balloon angioplasty stent angioplasty coronary artery bypass graft How many arteries were grafted? 1 2 3 4 3 or more bypass operations heart valve problem heart valve surgery balloon valvuloplasty stent valvuloplasty valve replacement lung infection (in last 30 days) diabetic retinopathy varicose veins surgery? YES tuberculosis pulmonary fibrosis use of home oxygen irregular heart beat or rate (arrhythmia, bradycardia, tachycardia, atrial fibrillation, palpitations) on medication pacemaker inserted external defibrillator internal defibrillator ablation heart murmur congestive heart failure coronary artery disease other Stroke / TIA stroke require any assistance with activities of daily living Muscle / Skeletal arthritis rheumatoid arthritis transient ischemic attack (TIA) or mini-stroke endarterectomy (surgery on your carotid arteries) prescribed blood thinner (for example Warfarin, Coumadin) osteoporosis, osteopenia degenerative disc disease (DDD) fibromyalgia herniated disc, spinal stenosis before stroke after stroke sciatica scoliosis spondylosis Please continue to the next page to tell us about symptoms, investigations and treatments. Page 3 of 5

Stomach or bowel (intestine or colon) condition (including gallbladder, hernia, throat and liver) Gallbladder gallbladder attack gallstones gallbladder removed Bowel/intestine or colon celiac disease inflammatory bowel disease (Crohn s disease, ulcerative colitis) diverticulosis diverticulitis undiagnosed intestinal or rectal bleeding (not including hemorrhoids) irritable bowel syndrome (IBS) Stomach gastric bypass surgery GERD, acid reflux or heartburn gastritis h. pylori hernia repaired? YES ulcer repaired? YES Liver liver disease hepatitis A B C cirrhosis of the liver Throat scleroderma, dysphagia, incoordination or achalasia Other Kidney or urinary condition Cancer Location: brain breast bone bowel, colon, intestine Hodgkin s lymphoma kidney leukemia liver lung ovarian / cervical kidney failure 2 or more urinary infections in last 12 months protein in urine kidney cysts prostate bladder skin stomach throat other cancer has spread to other organs of the body inoperable in remission eliminated kidney / bladder stones How many times have you had stones? 1 2+ other under treatment chemotherapy radiation treatment hormone replacement treatment surgery watchful waiting treatment is pending treatment declined other Uterine fibroids, ovarian cysts or prostate uterine fibroid surgery YES hysterectomy ovarian cyst surgery YES benign prostatic hypertrophy (BPH) on medication surgery Nervous system conditions anxiety / emotional disorder Parkinson s disease Guillain-Barre syndrome epilepsy or seizures Alzheimer s disease travelling alone YES require any assistance with activities of daily living migraines Pregnancy If you are female, are you currently pregnant? YES If yes, what is your expected delivery date? Page 4 of 5

Please tell us about the history of ALL your medical conditions you checked on page 2 and 3. We need to know about your symptoms, any investigations, treatments and prescriptions you ve had. Attach a separate sheet if necessary. Medical condition Medication prescribed Last dosage change Symptoms/investigation/treatment and date Declaration You declare that: The information you ve provided in this questionnaire is truthful, complete and accurate. You understand that: This questionnaire and the answers you provided are part of a contract provided through TIC Travel Insurance Coordinators Ltd. If your medical status or any of your answers changes between the date you complete this questionnaire and your departure date or the effective date of any extension, you must contact TIC prior to leaving on your trip to fully understand how your change in health affects the underwriting decision. Failure to do so may limit the amount of your claim payment or result in your claim being denied. The underwriting decision applies regardless of the sales medium and/or channel through which you purchase insurance. If a policy is issued to you that does not include this underwriting decision, it will be considered null and void, any premiums paid will be refunded and no claims will be payable. TIC will collect, use and/or disclose your personal information only to provide you with the insurance products and services you ve requested, for other uses authorized by you, or as required by law. You acknowledge that: If you misrepresent your medical status in this questionnaire, or if you don t disclose material information about your medical status, or if any of your answers are found to be incorrect or untrue, your coverage will be null and void, your claims won t be paid and your premium will be refunded, even if the material non-disclosure or inaccuracy is not related to the claim reported, and you will be solely responsible for all expenses related to your claim. This coverage is subject to exclusions, terms, conditions and limitations that may limit or exclude an amount payable. Authorization You authorize: Any organization or person that has records or knowledge of your health to give any and all information regarding your health, medical history and treatment to TIC Travel Insurance Coordinators Ltd. or its authorized representatives. You understand and agree that: If you refuse or withdraw this authorization your application will be denied. A copy of this authorization and declaration is as valid as the original. I HAVE READ AND UNDERSTOOD THE IMPORTANT INFORMATION IN THE STATEMENT ABOVE YES You must sign and date this questionnaire or it will be returned to you. Signature Signature date Page 5 of 5

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