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Services
Personal
Auto
Home
Life
Travel
Recreation
View all
Commercial
Auto
Property
Liability
Contractors
View all
Sanctuary Plus
Church
Missions
Program Highlights
View all
Program
Martial Arts
Pregnancy Care Canada
View all
About Us
Resources
Blog
Claims
After Hours Numbers
Information to Collect
Collision Reporting Centres
Contact Us
1 800 263 9870
1 800 263 9870
test form
tester
How did you find out about BrokerForce Insurance?
i.e. Google Search, Social Media, Referral (please let us know who referred you), etc.
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Address Line 2
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Date of Return
(Required)
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12
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2020
2019
2018
2017
2016
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2014
2013
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2011
2010
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2008
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1929
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1920
Please select your age range
0 - 59 years old
60+ years old
Eligibility Information (0-59 Years old):
(Required)
Yes, I confirm that I meet all of the below eligibility requirements.
To be eligible for coverage you must, as of the date you apply for coverage and the effective date:
1. Be at least 15 days old and no more than 59 years old; and
2. Be a resident of Canada and insured for benefits under a Canadian government health
insurance plan during the entire period of coverage; and
3. Not have been diagnosed with a terminal illness or received treatment for a terminal
condition for which a physician gave you a prognosis of eventual death or for which
palliative care was or is being received; or
4. Not have been diagnosed with stage 3 or 4 cancer; or metastatic cancer; or have received
treatment for any cancer (other than basal or squamous cell cancer or breast cancer
treated only with hormone therapy) in the last 3 months; or
5. Not require kidney dialysis; or
6. Not have been prescribed or used home oxygen in the last twelve (12) months; or
7. Never have had a bone marrow, stem cell or organ transplant (except corneal transplant);
or
8. not require assistance with activities of daily living (including but not limited to, eating,
bathing, using the toilet, changing positions, getting in/out of a bed or chair, getting
dressed) as the result of a medical condition or state of health; or
9. Not have been advised by a physician to avoid travel at this time, or for a period of time
which includes your trip
10. Not be travelling or going on your trip to receive treatment or alternative therapy of any
kind.
SMOKER STATUS
In the last two (2) years, have you smoked cigarettes, and/or used vaping products or e-cigarettes?
(Required)
Yes
No
PART 1 - RATE QUALIFICATION
Have you ever been diagnosed with or treated for a heart condition?
(Required)
Yes
No
Have you ever been diagnosed with or treated for any of the following conditions; Aortic aneurysm (including thoracic or abdominal aneurysm), Cirrhosis of the liver, Parkinson's disease, or Alzheimer's disease or other form of dementia?
(Required)
Yes
No
In the last three (3) months, have you taken or been prescribed a total of three (3) or more medications for high blood pressure (hypertension)?
(Required)
Yes
No
In the last five (5) years, have you been diagnosed with, taken or been prescribed medication for, or been treated for any of the following:
Lung condition (except unrepeated prescription medications used for single episode) (medication includes any puffer(s)/inhaler(s)?
(Required)
Yes
No
Stroke or mini-stroke/TIA (transient ischemic attack) (medication includes use of aspirin/Entrophen for this condition)?
(Required)
Yes
No
Diabetes (if treated with medication and/or insulin)?
(Required)
Yes
No
Narrowed or blocked artery in the legs or in the neck?
(Required)
Yes
No
PART 2 - RATE QUALIFICATION
In the last two (2) years, have you been diagnosed with, taken or been prescribed medication, or been treated for any of the following conditions:
Bowel obstruction or surgery?
(Required)
Yes
No
Diverticular disorder requiring prescription medication or surgery?
(Required)
Yes
No
Gastrointestinal bleeding?
(Required)
Yes
No
Chronic bowel disorder?
(Required)
Yes
No
Liver disorder?
(Required)
Yes
No
Pancreatic disorder?
(Required)
Yes
No
Kidney disorder (including stones)?
(Required)
Yes
No
Gallbladder disorder (including stones. If gall bladder has been removed, answer NO)?
(Required)
Yes
No
In the last two (2) years, have you been diagnosed with, and/or been treated by a Hematologist or an Internist for a blood disorder or a blood disease?
(Required)
Yes
No
In the last six (6) months, have you received advice or treatment for a medical emergency more than twice in the emergency room of a hospital?
(Required)
Yes
No
Are you over 70, and have you had a fall for which you sought medical attention in the last six (6) months?
(Required)
Yes
No
Eligibility Information (60+ Years old):
(Required)
Yes, I confirm that I meet all of the below eligibility requirements.
1. Be at least 15 days old,
2. Be a Canadian resident and be insured for benefits under a Canadian government health insurance plan during the entire Coverage Period,
3. Not have been advised against travel by a physician for a period of time which includes your trip, and
4. Not be traveling or going on your trip to receive treatment or alternative therapy of any kind.
- Canadian resident means a person legally authorized to reside in Canada and who maintains a permanent residence in Canada.
- The provincial and territorial government health insurance plans limit the time a person can be out of Canada and still remain eligible for provincial coverage. It is your responsibility to ensure you remain eligible during your Coverage Period. Check your province or territory’s health insurance plan for details.
5. In the two (2) years prior to the effective date, you must not have been diagnosed with or received treatment for a terminal condition for which a physician gave you a prognosis of eventual death or for which palliative care was or is being received.
6. If you are age 65 or older on the effective date, to be eligible for coverage you must not require assistance with activities of daily living including but not limited to, eating, bathing, using the toilet, changing positions(including getting in and out of a bed or chair), or dressing, as the result of a medical condition or state of health.
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