You declare that:
The information you’ve provided in this questionnaire is truthful, complete and accurate. You understand that:
• This questionnaire and the answers you provided are part of a contract provided through AZGA Service Canada Inc. o/a Allianz Global Assistance.
• If your medical status or any of your answers changes between the date you complete this questionnaire and your departure date or the effective date of any extension, you must contact Allianz Global Assistance prior to leaving on your trip to fully understand how your change in health affects the underwriting decision. Failure to do so may limit the amount of your claim payment or result in your claim being denied.
• The underwriting decision applies regardless of the sales medium and/or channel through which you purchase insurance. If a policy is issued to you that does not include this underwriting decision, it will be considered null and void, any premiums paid will be refunded and no claims will be payable.
• Allianz Global Assistance will collect, use and/or disclose your personal information only to provide you with the insurance products and services you’ve requested, for other uses authorized by you, or as required by law.

You acknowledge that:
If you misrepresent your medical status in this questionnaire, or if you don’t disclose material information about your medical status, or if any of your answers are found to be incorrect or untrue, your coverage will be null and void, your claims won’t be paid and your premium will be refunded, even if the material non-disclosure or inaccuracy is not related to the claim reported, and you will be solely responsible for all expenses related to your claim.
This coverage is subject to exclusions, terms, conditions and limitations that may limit or exclude an amount payable.

You authorize:
Any organization or person that has records or knowledge of your health to give any and all information* regarding your health, medical history and treatment to Allianz Global Assistance or its authorized representatives.

You understand and agree that:
• If you refuse or withdraw this authorization your application will be denied.
• A copy of this authorization and declaration is as valid as the original.

*Information excludes genetic tests. Genetic test means a test that analyzes DNA, RNA or chromosomes for purposes such as the prediction of disease or vertical transmission risks, or monitoring, diagnosis or prognosis.