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Travel Insurance Medical Questionnaire

Please answer the health questionnaire truthfully and accurately. If not, any claims could be subject to an additional $10,000 deductible. Your answers to these questions are used only to calculate your premium and do not determine your coverage for these conditions. If you have any doubt about your medical condition(s), please consult your physician for advice before completing this health questionnaire.

Have you ever experienced any of the following?

  • Myocardial infarction (heart attack) stroke and/or transient ischemic attack (TIA, mini-stroke)
  • Arterial by-pass/angioplasty and/or the placement of a stent for a cardiovascular condition
  • Organ transplant (excluding cornea and skin graft)

If yes, when did you last experience it?
  • Less than 12 months ago
  • 1-5 years ago
  • 5-10 years ago
  • More than 10 years ago

In the 12 months prior to the application date, have you had any conditions or symptoms listed below?

Even if only treated by medication, diet or active therapeutic device (ie. Pacemaker) these conditions or symptoms must be disclosed. This includes for the listed conditions, whether they’re stable or unstable. For the definition of stable, please see the policy wording at

  • Congestive heart failure (pulmonary edema - water on the lungs)
  • Narrowing or hardening of the arteries, coronary artery disease (stenosis, CAD, arteriosclerosis)
  • Ischemic heart disease (angina)
  • Arrhythmia, including atrial fibrillation (irregular heart rhythm, palpitations)
  • High blood pressure (hypertension)
  • High cholesterol


  • Asthma
  • Pneumonia
  • Chronic obstructive pulmonary disease (COPD; emphysema)
    not requiring home oxygen
  • Chronic obstructive pulmonary disease (COPD; emphysema)
    requiring home oxygen
  • Peptic ulcer (stomach or duodenal)
  • Diverticulitis (infection in lower bowel), bowel obstruction, Crohn’s disease or ulcerative colitis
  • Gastro-esophageal reflux disease (GERD; acid reflux)


  • Pancreatic cancer, liver cancer, or any other type of cancer that has metastasized or required a bone marrow transplant
  • Any other types of cancer (excluding basal cell and squamous cell skin cancer)
  • Cancer (excluding basal cell and squamous cell skin cancer) which has been removed within or in remission for less than 10 years
  • Diabetes requiring insulin
  • Diabetes not requiring insulin
  • Kidney stones
  • Kidney disease not requiring dialysis
  • Kidney disease requiring dialysis
  • Dementia (including Alzheimer’s disease)
  • Smoked tobacco products
  • Liver disease

*If you qualify for the coverage selected but you or a representative purchasing insurance on your behalf have failed to answer truthfully and accurately any question asked in the Health Questionnaire, any claim will be subject to an extra deductible of $10,000 in addition to any other deductible amount and no future coverage will be provided under this Policy unless you pay the additional premium reflecting true and accurate answers to those questions. I understand that the medical conditions disclosed on this questionnaire may not be covered. Details related to pre-existing conditions coverage are set out in the Policy booklet.

Travel Insurance is sold through B.C.A.A. Holdings Ltd. dba BCAA Insurance Agency, a licensed insurance agent and is underwritten by BCAA Insurance Corporation. The insurance transaction is between the customer and BCAA Insurance Corporation. BCAA Insurance Corporation and B.C.A.A. Holdings Ltd. are both subsidiaries of British Columbia Automobile Association and B.C.A.A. Insurance claims are administered by Orion Travel Insurance, a division of Echelon Insurance, and its subcontractors, Active Care Management (2018) Inc. and Global Excel Management Inc.