King Insurance

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Traveler Name 1:

Traveler Name 2:

Address:

Address 2 (if different):

Date of Birth of Traveler 1:

Date of Birth of Traveler 2:

Your Email Address:

Your Phone Number(s):

Name of Person Filling out Application:

Departure Date:

Return Date:

Length of Trip:

Destination:

Pre-Existing Conditions

1. Have you been advised by a Physician not to travel?
   Traveler 1 Traveler 2
2. Do you have AIDS?
   Traveler 1 Traveler 2
3. Have you been diagnosed with a terminal illness?
   Traveler 1 Traveler 2
4. Have you ever received an organ transplant?
   Traveler 1 Traveler 2
5. In the last 12 months have you:
   • Been hospitalized for 48 hours or more?
     Traveler 1 Traveler 2
   • Received treatment in an Emergency Room?
     Traveler 1 Traveler 2
   • Had a lung condition which required hospitalization?
     Traveler 1 Traveler 2
6. Has it been longer than 18 months since your last medical check-up?
   Traveler 1 Traveler 2
7. Do you have a heart condition?
   Traveler 1 Traveler 2
8. Had a Heart Murmur? / Irregular Heartbeat? / Pacemaker?
   Traveler 1 Traveler 2
9. Have you been diagnosed with congestive heart failure?
   Traveler 1 Traveler 2
10. Have you had a previous heart attack? / heart surgery?
    Traveler 1 Traveler 2
    • Describe (what, when) #1:
      
    • Describe (what, when) #2:
      
11. Have you received treatment/medication for high blood pressure?
    Traveler 1 Traveler 2
12. Have you received treatment/medication for high cholesterol?
    Traveler 1 Traveler 2
13. Have you ever been diagnosed with angina?
    Traveler 1 Traveler 2
14. Have you ever been prescribed nitro?
    Traveler 1 Traveler 2
15. Do you have diabetes?
    Traveler 1 Traveler 2
    • How is it controlled? #1:
      
    • How is it controlled? #2:
      
16. Do you have asthma?
    Traveler 1 Traveler 2
17. Have you been prescribed to carry a puffer?
    Traveler 1 Traveler 2
18. Have you required home oxygen? / Steroids for a lung condition?
    Traveler 1 Traveler 2
19. Have you ever been diagnosed with dementia or Alzheimer’s?
    Traveler 1 Traveler 2
20. Have you been diagnosed with cancer in the last 5 years?
    Traveler 1 Traveler 2
    • Last treatment date? #1:
      
    • Last treatment date? #2:
      
    • Form of treatment if within last 12 months: #1:
      
    • Form of treatment if within last 12 months: #2:
      
21. Do you have a kidney disease? / Kidney stones? / Receive dialysis?
    Traveler 1 Traveler 2
22. Have you ever had a stroke? / Mini-stroke? / TIA?
    Traveler 1 Traveler 2
23. Have you ever been diagnosed with Peripheral Vascular Disease? (clogged artery in the leg or neck)
    Traveler 1 Traveler 2
24. Have you ever had an aneurysm?
    Traveler 1 Traveler 2
25. Have you been diagnosed with any of the following:
    • Liver disease?
      Traveler 1 Traveler 2
    • Gastro Intestinal Bleeding?
      Traveler 1 Traveler 2
    • Chronic Bowel Disease?
      Traveler 1 Traveler 2
    • Bowel Obstruction? / Surgery?
      Traveler 1 Traveler 2
    • Gallbladder Disease?
      Traveler 1 Traveler 2
    • Pancreatitis?
      Traveler 1 Traveler 2
    • Hemochromatosis?
      Traveler 1 Traveler 2
    • MS?
      Traveler 1 Traveler 2
    • Lou Gehrig’s?
      Traveler 1 Traveler 2
    • Lupus?
      Traveler 1 Traveler 2
    • Epilepsy?
      Traveler 1 Traveler 2
    • ITP?
      Traveler 1 Traveler 2
    • Scleroderma?
      Traveler 1 Traveler 2
26. Are you taking medication for arthritis and/or osteoporosis?
    Traveler 1 Traveler 2
27. Have you had a fall that has been reported to your Physician?
    Traveler 1 Traveler 2
28. Have you been prescribed/taken Lasix or Furosemide in last 2 years?
    Traveler 1 Traveler 2
29. Are you a smoker? / Used any tobacco products in last 5 years?
    Traveler 1 Traveler 2
30. Are you booked or awaiting further treatment, tests and/or investigation for any condition?
    • If yes, describe #1:
      
    • If yes, describe #2:
      
31. Do you require Baggage / Trip Cancellation insurance?
    Traveler 1 Traveler 2
32. List medications taken in past 12 months and purpose of medications:
    • Person #1:
      
    • Person #2:
      
33. List any prescriptions which have changed in past 12 months (including increases and decreases in dosage):
    • Person #1:
      
    • Person #2:
      
34. Additional information:
    • Person #1:
      
    • Person #2:
      

I have provided personal information in this document and otherwise and I may in future provide further personal info. Some of this personal info may include, but is not limited to, my credit info and claims history. I authorize my broker or insurance company to collect, use and disclose any of this personal info, subject to the law and to my broker’s insurance company’s policy regarding personal info, for the purpose of communicating with me, assessing my application for insurance and underwriting my policies, evaluating claims, detecting and preventing fraud, and analyzing business results. I confirm that all individuals whose personal info is contained in this document have authorized that I agree to the above on their behalf.

I agree and understand the above paragraph

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