Coverage Details:

Allowances (up to maximum 5%):

Eligibility

To be eligible for coverage under the contract, as of the Effective Date, a Person Insured must:

1. not be eligible for benefits under a Government Health Insurance Plan;

2. be a visitor to Canada; or

3. be a Canadian citizen or permanent resident returning to reside in Canada;

4. be at least 15 days old and less than 90 years of age;

5. be the Policyowner, unless the sole Person Insured is under the age of 18 (if in Quebec) or age 16 (all other Canadian provinces or territories), in which case the Policyowner must be the Person Insured’s parent or legal guardian;

6. if not the Policyowner, be a Spouse or Dependent of the Policyowner; and

7. be insurable in accordance with Our then-current underwriting rules.

A Person Insured is not eligible for coverage under the contract if, as of the Effective Date, any of the following applies to a Person Insured, even if disclosed on the Application:

• They are travelling or planning to travel to Canada against the advice of a Physician;

• They have received a Terminal Prognosis;

• They are experiencing new or undiagnosed signs or symptoms of a Sickness for which they reasonably expect may require Treatment while the contract is in force, or otherwise have a reasonably foreseeable need for Treatment while the contract is in force;

• In the 3 years prior to the Effective Date, they have received Treatment for aplastic anemia, hemolytic anemia, sickle cell anemia, or anemia requiring blood transfusions or bone marrow transplants, or have received Treatment in a Hospital for anemia through iron supplements;

• They have had a bone marrow transplant, stem cell transplant or an organ transplant (but excluding cornea transplants);

• In the 6 months prior to the Effective Date, they have been Hospitalized for a Sickness;

• They are residing in a nursing home, rest home, convalescent home, rehabilitation centre or home for the aged;

• Except as required by minors due to their age, they require assistance with any activities of daily living (i.e., bathing, eating, using a toilet, taking medication(s) or getting into or out of a chair or bed); or

• In the 12 months prior to the Effective Date, they have:

  1. been prescribed home oxygen (including an oxygen concentrator) or prednisone for a lung condition or heart condition;

  2. had pulmonary fibrosis or cystic fibrosis;

  3. used nitroglycerine in any form (spray, patch, or pill) for a heart condition for the relief of angina or chest pain, or had heart condition with an ejection fraction of less than 40%; or

  4. had any aneurysm that is not surgically repaired.

If the Company determines that a Person Insured was not eligible on the Effective Date, the contract is null and void and is deemed to have never taken effect, no benefits will be payable and premiums may not be refunded in cases of fraud.

DECLARATION OF APPLICANT/PERSON INSURED

1. I have read, or the broker has read to me, the Eligibility Requirements above and I understand them; and

2. I declare that, based on such requirements, each person insured named on this application is eligible for the travel insurance being applied for and that I am authorized to make such declaration on behalf of each person insured named in this application.

I acknowledge and agree that:

1. Approval of this application will be based on the above declaration that each proposed person insured is eligible for the travel insurance being applied for is true and the answers and statements given in the application are true and complete; and

2. In the event such declaration or any answers or statements recorded on the application contain any misrepresentation or non-disclosure of a material fact, the insurer may void the insurance contract, no benefits will be paid, and premiums may not be refunded, in cases of fraud.

I confirm I am eligible.