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Medipac Travel Insurance Form

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MEDIPAC TRAVEL EMERGENCY MEDICAL INSURANCE APPLICATION 2010-2011

If you are travelling for less than 41 days and you are under the age of 61, you do not have to complete sections A, C and D of this application. If you are uncertain of your answer to any of the medical questions, consult your doctor.

A. Eligibility

Please answer all questions for Applicant 1 and Applicant 2.

Question Applicant 1 Applicant 2
1. Have you been diagnosed as having a terminal illness, been advised by a physician not to travel or do you have HIV, AIDS or AIDS-related complex? Yes No Yes No
2. Have you EVER had an organ or bone marrow transplant (excluding cornea or skin graft)? Yes No Yes No
3. During the 5 YEARS prior to the date of this application, have you been treated for, taken or been prescribed medication for, or been diagnosed with Lung Cancer or Metastatic Cancer? Yes No Yes No
4. Do you HAVE a cardiac condition with an ejection fraction of LESS THAN 40% or a ventricular function grade of 3 or 4? Yes No Yes No
5. Do you HAVE Moderately Severe or Severe Cardiac Valve Stenosis? Yes No Yes No
6. Do you HAVE an Aneurysm greater than 4.0 cm in size which remains surgically untreated? Yes No Yes No

B. Personal Information

Applicant 1

Name:

Date of Birth: Male Female

Provincial Health Card #:

Version Code:

Pre-retirement employer:

Position:

Have you smoked cigarettes in the 3 years prior to the date of this application? Yes No

Doctor's Name:

Phone:

Specialist's Name:

Phone:

Specialty Type:

Emergency Contact:

Phone:

Applicant 2

Name:

Date of Birth: Male Female

Provincial Health Card #:

Version Code:

Pre-retirement employer:

Position:

Have you smoked cigarettes in the 3 years prior to the date of this application? Yes No

Doctor's Name:

Phone:

Specialist's Name:

Phone:

Specialty Type:

Emergency Contact:

Phone:

Canadian Address (Both Applicants)

Street Name & Number:

Apt #: Lot #: City:

Province: Postal Code:

E-mail:

Phone:

Out-of-Country Address (Both Applicants)

Permanent Address Temporary Address

Street Name & Number:

Apt #: Lot #: City:

State: Zip Code:

E-mail:

Phone:

Please mail my insurance policy to my: Canadian Address Out-of-Country Address

C. Rate Qualification - Part 1

Question Applicant 1 Applicant 2
1. Have you EVER had Congestive Heart Failure or Heart surgery of any kind? Yes No Yes No
2a. During the 5 YEARS prior, have you been diagnosed with narrowing or blockage of any Artery, an Aneurysm, a Heart Attack, any Heart Condition or Angina? Yes No Yes No
2b. Chronic Lung Disease including Emphysema, COPD or Chronic Bronchitis? Yes No Yes No
2c. Stroke or Transient Ischemic Attack (TIA) or Ministroke? Yes No Yes No
3a. During the 2 YEARS prior, have you been diagnosed with Chronic Bowel Disease or Disorder, Pancreatitis or Gastrointestinal Bleeding? Yes No Yes No
3b. Asthma for which you have taken or been prescribed Prednisone, Solu-Medrol or two or more inhalers? Yes No Yes No
4. During the 12 MONTHS prior, have you been diagnosed with Cancer or Malignant Tumours? Yes No Yes No
5a. During the 3 MONTHS prior, have you taken or been prescribed Lasix or Furosemide? Yes No Yes No
5b. During the 3 MONTHS prior, have you taken or been prescribed 3 or more medications for Diabetes, Hypertension or both? Yes No Yes No
6. Have you been diagnosed with Lou Gehrig’s Disease, Muscular Dystrophy, Myasthenia Gravis, Cerebral Palsy, Multiple Sclerosis or Dementia? Yes No Yes No
7. Do you HAVE Cirrhosis of the Liver, or moderate or severe Kidney failure? Yes No Yes No
8. Do you HAVE Insulin dependent Diabetes? Yes No Yes No

D. Rate Qualification - Part 2

QuestionApplicant 1Applicant 2
1. Have you EVER had narrowing or blockage of any Artery, a Heart Attack, any Heart Condition or Angina? Yes No Yes No
2. Have you EVER had a Stroke or Transient Ischemic Attack (TIA) or Ministroke? Yes No Yes No
3. Do you HAVE Diabetes requiring oral medication? Yes No Yes No
4a. During the 2 YEARS prior, have you been diagnosed with a Blood Disorder by an Internist or Hematologist? Yes No Yes No
4b. Epilepsy or any other Seizure Disorder? Yes No Yes No
4c. Parkinson’s Disease? Yes No Yes No
4d. Transient Global Amnesia? Yes No Yes No
5. During the 12 MONTHS prior, have you had a Fainting Spell or a Syncopal Episode? Yes No Yes No
6a. During the 3 months prior, have you taken or been prescribed Prednisone or Solu-Medrol? Yes No Yes No
6b. Any Immunosuppressive Drugs? Yes No Yes No

E. Travel Information

Applicant 1 / Other Insurance Coverage

Name of Plan:

Number of days covered:

Insurance Company:

Single Coverage Family Coverage

Policy #:

Certificate #:

I am a Superannuate and request the CDN$500,000 deductible for the first 40 days of my trip.

I request my policy be issued with a deductible of CDN$100,000 for the first 40 days of my trip.

Topping up? Effective Date of Insurance:

Date of Departure: Scheduled Return Date:

Applicant 2 / Other Insurance Coverage

Name of Plan:

Number of days covered:

Insurance Company:

Single Coverage Family Coverage

Policy #:

Certificate #:

I am a Superannuate and request the CDN$500,000 deductible for the first 40 days of my trip.

I request my policy be issued with a deductible of CDN$100,000 for the first 40 days of my trip.

Topping up? Effective Date of Insurance:

Date of Departure: Scheduled Return Date:

F. Premium Calculation

Applicant 1

Rate Category:

Select USD Deductible:

Discount Authorization Code:

Age at Departure:

Single Trip Rate for Applicant 1:

Total discount: ( ) %

Subtotal:

Add Annual Add-on Rate:

Rate Subtotal:

Add 10% if taking a $0 Deductible:

Subtotal:

Add 15% if smoked in prior 3 years:

Add $20 Top-Up fee or subtract Federal Superannuate Credit:

Add $39 for MedipacPLUS:

Total Premium for Applicant 1:

Applicant 2

Rate Category:

Select USD Deductible:

Discount Authorization Code:

Age at Departure:

Single Trip Rate for Applicant 2:

Total discount: ( ) %

Subtotal:

Add Annual Add-on Rate:

Rate Subtotal:

Add 10% if taking a $0 Deductible:

Subtotal:

Add 15% if smoked in prior 3 years:

Add $20 Top-Up fee or subtract Federal Superannuate Credit:

Add $39 for MedipacPLUS:

Total Premium for Applicant 2:

G. Payment Option

Please make your cheque payable to Medipac International Inc.

Cardholder Name: Visa MasterCard

Card #:

Expiry Date: Month Year

Check here if, in the event of a claim, you would like your deductible charged to your credit card.

All premiums are in Canadian dollars.

H. Declaration / Authorization

IMPORTANT NOTICE: This application must be completed, dated and signed in Canada prior to departure.

I certify that all answers and information provided by me in this application are true and complete to the best of my knowledge and belief. I understand that in applying for coverage under this policy it is my responsibility to be aware of all my medical conditions. I agree that any false or misleading statement in the making of this application shall render any resulting policy NULL and VOID.

I acknowledge receipt of and confirm my agreement with the NOTICE ON EXCHANGE OF INFORMATION and a NOTICE ON PRIVACY AND CONFIDENTIALITY.

I hereby authorize Medipac International Inc. to use my name, address and date of birth for additional products and services, but this consent is optional.

I further understand that all answers to all questions in this application must be and remain true up to and including the Effective Date of Insurance, otherwise my coverage will be NULL and VOID.

Date Signed:

Applicant 1 Signature:

Applicant 1 Print Name:

Applicant 2 Signature:

Applicant 2 Print Name:

Please DATE and SIGN below

Instruction Card / Checklist

Please read the instruction card carefully before beginning your application. Ensure all medical questions are completed, departure and return dates are provided, and all signatures and dates are included.

All medical questions have been answered.

You have indicated your departure and return dates, trip length and deductible.

Your cheque or credit card payment is included.

Each applicant has signed and dated Section H.

Any changes you made to the application have been initialed by the individual applying for insurance.

Administration Use Only

Applicant 1 Policy #:

Checked By:

Processed By:

Applicant 2 Policy #:

Notes:

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What the Medipac Travel Insurance Form Is

The Medipac Travel Insurance Form is the standard policy and claims document used to enroll travelers, record health and trip details, and request medical reimbursement or assistance during travel. The form collects personal identification, trip dates, pre-existing condition disclosures, coverage selections, emergency contact details, and payment authorization. Insurers use the completed form to underwrite short-term travel medical coverage, verify eligibility, and process emergency evacuations or claims. Submitted copies become part of the policy record and may be required when receiving care abroad or when seeking reimbursement after return.

Why the Medipac Travel Insurance Form Matters

A completed form documents coverage limits, emergency assistance consent, and billing authorizations so insurers can triage medical events, coordinate care, and process claims accurately and consistently.

Why the Medipac Travel Insurance Form Matters

Who Typically Completes or Receives This Form

Profiles below show common filer and recipient roles when using the Medipac Travel Insurance Form.

  • Individual travelers and policyholders who need emergency medical coverage while abroad or away from home.
  • Travel agents and tour operators collecting traveler information for group policies or coordinated evacuation services.
  • Employer or HR travel managers arranging corporate short-term coverage for employees on business travel.

Use these roles to determine who must sign, who must receive copies, and who handles claims and appeals.

Step-by-step: Completing the Form from Start to Finish

Gather identification, travel itinerary, medical history, and payment method before you begin to reduce errors and speed submission.

  • 01
    Collect Documents: Passport/ID, itinerary, prior medical records if needed.
  • 02
    Enter Personal Data: Full legal name, DOB, address, and contact details.
  • 03
    Choose Coverage: Select plan, limits, and deductibles applicable to trip.
  • 04
    Sign & Submit: Sign, date, and send via chosen submission method.

Online form configuration and delivery settings

If completing or hosting an online version, configure authentication, conditional fields, notifications, and storage to match insurer requirements.

Field Configuration
Authentication Email plus optional SMS code
Conditional Fields Show medical questions if coverage selected
Notifications Email confirmation to policyholder and agent
Storage Format PDF with audit trail

Where to submit the completed Medipac Travel Insurance Form

Choose the method your insurer or broker accepts and retain proof of submission for claims and audits.

  • Secure Portal: Upload via insurer or broker secure claims portal.
  • Email Submission: Attach PDF to insurer email address if permitted.
  • Physical Mail: Send signed originals when requested by the insurer.
  • Agent Upload: Authorized travel agent may submit on your behalf.

Technical and format requirements for digital submission

Confirm acceptable file types, authentication level, and record-keeping expectations before e‑submitting the form.

  • File formats: PDF, DOCX, or scanned image
  • Authentication: Email link or SMS OTP
  • Integrations: CRM and cloud storage

Essential sections and clauses to expect on the form

A professional Medipac Travel Insurance Form collects identification, medical disclosures, coverage selections, authorizations, payment details, and legal notices in clear, discrete sections.

Personal Details

Collects full legal name, date of birth, citizenship, and contact information needed to verify identity and coordinate medical care or evacuations.

Medical History

Requests current medications, ongoing conditions, and recent treatments so underwriters can assess coverage eligibility and pre-existing condition exclusions.

Coverage Selection

Specifies plan tier, limits, deductibles, and optional riders such as evacuation, repatriation, or hazardous activity coverage.

Claim Authorization

Provides consent for the insurer to obtain medical records, release information to providers, and coordinate direct billing when permitted.

Emergency Assistance Consent

Authorizes emergency medical evacuation, repatriation, and coordination of in‑country providers consistent with policy terms.

Payment and Billing

Captures premium payment method, payer details, and whether refunds or reimbursements are payable to the insured or a third party.

Security and compliance features to verify

Encryption: TLS 1.2/1.3; AES-256 at rest
Audit Trail: Timestamped signer events
HIPAA Support: BAA available when required
Authentication: Email, SMS, or MFA
Certifications: SOC 2 Type II, ISO 27001
Accessibility: WCAG 2.0 Level AA

Risks and consequences of incorrect or incomplete forms

Claim Denial: Missing or false information may lead to claim refusal
Delayed Processing: Incomplete fields extend review and reimbursement times
Coverage Gaps: Wrong plan selection can leave you uninsured
Privacy Breach: Improper handling of PHI risks HIPAA penalties
Disputed Billing: Incorrect payer info causes payment disputes
Administrative Fines: Failure to follow state insurance rules may incur penalties

Common mistakes that slow claims or cause denials

  • Using a nickname or abbreviated name that does not match government photo ID leads to identity verification failures and claim delays.
  • Failing to disclose recent medical treatment or ongoing conditions can trigger pre-existing condition exclusions and claim denials.
  • Entering incorrect travel dates or destination can create coverage gaps if the illness or event falls outside the stated period.
  • Not providing an emergency contact or up-to-date phone number prevents timely coordination of care or evacuation when seconds matter.

Typical deadlines and expected processing times

Insurers and brokers have different deadlines; confirm the timetable with the issuing insurer and keep submission receipts for appeals.

Enrollment Deadline:

Complete enrollment before departure for full pre-trip coverage

Claim Filing Window:

Most insurers request claims within 30–90 days of treatment

Proof Submission:

Submit medical reports and receipts within insurer-specified timeframes

Reimbursement Processing:

Reimbursements commonly take 30–45 days after claim acceptance

Appeal Period:

Appeals typically must be lodged within insurer-defined windows, often 30–60 days

Comparing eSignature options for processing Medipac forms

Pricing and feature differences matter for high-volume Medipac workflows; the table below summarizes starting prices and core capabilities across vendors.

signNow DocuSign Adobe Sign PandaDoc HelloSign
Starting Price $8/user/mo $15/user/mo $14/user/mo $19/user/mo $15/user/mo
Free Trial 7-day trial Varies Varies Varies Varies
Bulk Send Yes Yes Yes Yes No
Audit Trail Yes Yes Yes Yes Yes
HIPAA Compliant Yes Yes Yes No No
Envelope Cap No cap 100 envelopes/user/year Varies Varies Varies

Frequently asked questions and troubleshooting

Answers to common questions about acceptance, electronic signatures, notarization, and privacy when using the Medipac Travel Insurance Form.


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