GMS Immigrants & Visitors to Canada Application

About Us
Why Use Us?
Plans
Services
Direct Sales
Medical Complications
- Medical Tourism & Complications Travel Insurance
Links
FAQ

About Us
Why Use Us?
Plans
Services
Direct Sales
Medical Complications
- Medical Tourism & Complications Travel Insurance
Links
FAQ

Important Information

• There are specific expenses that are not covered by this plan. Make sure you read the Exclusions to Coverage section in the policy wording.
• Expenses related to pre-existing conditions, or symptoms that happened before your effective date may not be covered by this plan. Reading the details found in the policy wording’s Exclusions to Coverage section is important to understand how they apply to you.
• If there is a change in your health after the application date and prior to the effective date, GMS must be notified and the application updated. A change in your health may affect your eligibility for coverage. Changes to your health that do not affect eligibility will still constitute a change in stability and may limit your available coverage.
• Where this policy is issued to satisfy entry to Canada, GMS reserves the right to notify Citizenship and Immigration Canada if the policy is cancelled.
• If you experience a medical emergency, you must notify the GMS assistance firm prior to treatment, where possible, and no later than 24 hours after receiving medical treatment or being admitted to hospital. Your policy may limit benefits should you not contact the assistance firm.
• In the event of a medical emergency you must call GMS Assistance:
Toll-free (within Canada and the USA): 1 800 459 6604
Collect (from all other locations): 905 762 5196
• In the event of a claim or refund request documentation confirming travel dates will be required.
• Depending on your province of residence the premium charged may be subject to tax.

• medical treatment: any medical, therapeutic or diagnostic measure prescribed or recommended by a physician in any form, including; prescription medication; investigative testing; in-hospital care; surgery; or other prescribed or recommended action directly referable to the applicable condition, symptom or problem.

• heart disease: any disease of the heart including, but not limited to: angina, irregular heartbeat, heart attack, congestive heart failure, ischemic heart disease, valvular heart disease, and myocardiopathy.
oral steroids: are steroids that are swallowed to treat a lung condition. They do not include steroids that are inhaled to prevent asthma attacks or to temporarily treat and relieve inflammation of the airway.

• stable: when applying, a medical condition is stable if:
1. you have no reason to expect medical treatment for the medical condition
or any symptoms after your effective date;

In the 12 months before your application date:
2. you have not received new or different medical treatment for the medical condition;
3. you have not had an alteration to an existing prescription drug or were prescribed a new prescription drug for the medical condition;4. , your medical condition has not become worse;
5. you have not experienced new, more frequent or more severe symptoms;
6. you have not had or needed medical consultation for undiagnosed symptoms;
7. you have not needed in-hospital care; a referral to a specialist, or a follow-up visit; and
8. you have not had tests or an investigation, whether you know the results or not, related to the medical condition.

alteration: an alteration to an existing prescription drug includes any of the following:
• a new medication
• a change in medication type
• an increase or decrease in medication dose
• the discontinuation of a medication; or
• an adjustment (stop and start) in an anticoagulation medication dosage due to surgery within ten (10) days before your application date.

The following alterations resulting from the regular maintenance of a condition where there is no change in the condition are not considered an alteration:
• a dosage adjustment for an anti-hypertensive or cholesterol lowering medication;
• a change from a brand name medication to a generic brand medication of the same dosage;
• if you are taking Coumadin/Warfarin for anticoagulation therapy and are required to have your blood levels tested on a regular basis (INR) and you are adjusting the dosage of your anticoagulation medication to ensure your INR is maintained within therapeutic range as directed by your physician(s); or
• if you are taking insulin or oral anti-diabetic medication for diabetes and are required to have your blood levels tested on a regular basis and you are adjusting the dosage of your medication to ensure your blood glucose level is maintained within therapeutic range as directed by your physician(s).

• medical consultation: a meeting with a physician to discuss and evaluate symptoms to diagnose a medical condition, illness or injury. It also includes meeting with a physician to evaluate your progress and medical treatment

• terminal illness: a disease that cannot be cured and is reasonably expected to result in death.

1Applicant Information

2Eligibility

3Trip Information & Premium Calculation

4Declaration, Signature, Payment

GMS Immigrants & Visitors to Canada

A. Applicant Information

Please choose one

You are outside Canada (No waiting period)
You are in Canada and purchasing this plan to replace an existing Canadian health insurance plan (No waiting period)
You have been in Canada for less than 30 days without a Canadian health insurance plan. (48 hour waiting period)
You have been in Canada for more than 30 days without a Canadian health insurance plan (7 day waiting period)

Date first arrived in Canada

Insurance company

Policy #

Expiry Date

Name

First

Last

For more than two applicants, please complete an additional application form or apply online at www.gms.ca
????????????????????

Birth Date

Gender

M
F

Country of Origin

Canadian Address

Address Line 1

Address Line 2

City

State / Province / Region

Postal Code

Country

This plan is not offered in Quebec and New Brunswick

Phone

Local Contact and Phone Number

In Case of Emergency

Email

B. Sponsor Information

Would you like to add a sponsor to this plan?

Yes

By checking “Yes” you are authorizing GMS (Group Medical Services) to share information about your policy, any claims under your policy, and personal health information with your sponsor; and send any payments paid out under the policy to your sponsor. You can remove your sponsor at any time by contacting GMS or your broker.

Sponsor's Name

First

Last

Is the sponsor’s address the same as the address listed in section A. Applicant Information?

Yes
No

Sponsor's Address

Address Line 1

Address Line 2

City

State / Province / Region

Postal Code

Country

This plan is not offered in Quebec and New Brunswick

Sponsor's Phone

Sponsor's Email

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Eligibility

Eligibility questions determine if you are eligible to purchase a GMS Immigrants & Visitors to Canada Plan. The questions you need to answer are based on your age. If you are under 55 years of age, answer questions 1-3. If you are between 55 and 69 years of age, answer questions 1-12. If you are between 70 and 79 years of age, answer questions 1-13. Please note, some words have very specific meanings. Those words are defined.

Age

Under 55
Between 55 - 69
Between 70 - 79

1. Do you have any reason to see a physician; visit a hospital or clinic; or obtain medical treatment?

Yes

2. If you are currently in Canada, have you ever been denied similar coverage offered by another Canadian insurer?

Yes

3. If you are currently in Canada, have you had more than $5,000 in medical treatment in the last 12 months while in Canada?

Yes

4. Are you:

a. expecting medical treatment for heart disease;
b. waiting for a test(s) for a suspected heart condition; and/or
c. taking prescription drugs for heart disease while taking insulin to treat diabetes?

5. Do you have an Implantable Cardioverter Defibrillator (ICD)?

Yes

6. Have you fainted or fallen more than once without medical diagnosis (syncope)?

Yes

7. Do you use home oxygen for a medical condition?

Yes

9. Are you being treated for cancer or have Metastatic Cancer?

Yes

10. Do you have a vascular aneurysm that is surgically untreated?

Yes

11. Have you ever had:

a. valve replacement
b. kidney (renal) dialysis, or
c. an organ transplant?

12. Do you have a medical condition from the list below that has not been stable for 12 months before your application date?

a. Congestive Heart Failure
b. Atrial flutter
c. Atrial/ventricular fibrillation
d. Peripheral vascular disease
e. Stroke/transient ischemic attack (TIA)
f. Acquired Immune Deficiency Syndrome (AIDS)
g. Terminal Illness
h. Blood Clot(s)
i. Gastrointestinal Bleeding

13. Do you need help from another person(s) with activities of daily living (ADL), including but not limited to: personal hygiene and grooming; dressing and undressing; feeding yourself; getting into and out of bed, a chair, a wheelchair, the toilet, etc; bowel and bladder management; and/or managing your medication?

Yes

If you checked or answered YES to any of the eligibility questions YOU ARE NOT eligible to purchase a plan.

I am eligible

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Trip Information

Note: GMS Immigrants & Visitors to Canada Plans are available to a maximum of 365 days, including all extensions. For policies less than 365 days, an extension to your trip may be requested by contacting your broker or info@gms.ca. To be eligible to extend your policy you must not have incurred any medical services during your trip.

Effective Date of Coverage

Expiry Date of Coverage

Length of Coverage (# of days)

Notes:
• The total # of days for your trip including effective and expiry dates
• # of days calculator can be used: here

E. Premium Calculation

efer to the GMS Immigrants & Visitors to Canada brochure for daily rates

Deductible

$0
$100
$500
$1,000

Daily Rate for coverage limit chosen

# of days purchased

Premium

Amount of Insurance

$25,000
$50,000
$100,000
$150,000

Total Premium ($CAD)

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Declaration

I/We (“I”) declare the statements made herein are true and complete and shall form part of my application for coverage. I hereby authorize any physician, health care provider, other person, hospital, institution, or insurance company to release to Group Medical Services and/or its authorized agents, representatives, affiliates or other service providers (collectively “GMS”) any information covering my medical history, symptoms, treatment, examination, diagnosis and/or services rendered to myself or any of my dependants herein listed.

For the purposes of administering any Group Medical Services (“GMS”) benefits, products or services (collectively “benefits”) and/or determining eligibility for benefits, I authorize GMS to: (a) collect, store and use any personal information which I have provided to GMS or personal information obtained pursuant to clause (b); and/or (b) obtain personal information about me (or any other person listed herein) from, or disclose such personal information to: my Government Health Insurance Plan; the operator of any hospital, clinic, or other health facility; a doctor or other health care provider; any insurance company; or any other service provider or third party as may be reasonably required for the purposes described above.

I understand that, whether before or after my application, any misrepresentation, incorrect or concealed information or failure to fully complete all sections of the application may void my coverage. I declare that, if I am signing on behalf of any person(s), I have the authority to sign on behalf of such person(s) listed herein and confirm that each of the above declarations and authorizations are also provided on behalf of such person(s).

I warrant that neither I, nor any person herein listed, have any additional coverage through any insurer other than the information listed herein. Should I, or any person herein listed, subsequently obtain additional coverage through any insurer, while covered under this contract, I will immediately advise GMS in writing. I hereby authorize GMS to coordinate any eligible expenses with any additional insurer that I, or any person herein listed, may have coverage under.

Signature

Clear Signature

Date

Payment method