Simpson Group
Simpson Group

Allianz Medical Questionnaire

Based on your age and travel details, you will be required to complete a medical screening in order to obtain a quote.

Our goal is to make sure that you have the coverage you need for your upcoming trip. It is important to answer accurately so that you have coverage in the event that you need to make a claim

Any misrepresentation or nondisclosure may void your policy and leave you without coverage. Allianz may access your medical records to confirm the following responses are accurate. Consult with your physician if you are unsure how the following questions relate to your health.

If your health changes in any way before your trip, consult with your physician, then notify your insurance representative to see how this may affect your coverage.

Answer the following questions as of the date you are filling out this questionnaire.

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Allianz Medical Questionnaire

Name
1. In the past 6 months have you been prescribed, refilled or taken prescription medication, other than birth control, low-dose aspirin, or antibiotics?

Specifically, in the past 6 months have you been prescribed, refilled or taken prescription medication for:

2. Have you been diagnosed with or had any cancer treatment in the past 6 months (this does not include basal or squamous cell skin cancer or breast cancer treated only with hormone therapy)?
3. Have you used any tobacco or nicotine products in the past 6 months?