TRAVEL INSURANCE CERTIFICATE

CONTRACT NUMBER : DL80695

POLICY HOLDER

Youssef Ouchhoutta
517, MACKAY STREET
PEMBROKE ON K8A 1E7 DISTRIBUTOR
DISTRIBUTOR NAME : BLUE CROSS
DISTRIBUTOR NUMBER : 10000

PRODUCT : Visitors to Canada - Foreign TYPE OF PLAN : Individual

worker STATUS : Application
PURCHASE DATE : September 21, 2023 EXPIRY DATE : October 20, 2023
EFFECTIVE DATE : September 21, 2023 MAXIMUM STAY : 30 days
TRANSACTION DATE : September 21, 2023

It is VERY IMPORTANT that

COVERED PERSON(S)
you read your policy over
Youssef Ouchhoutta 33
carefully as it contains certain
restrictions. In addition, please
COVERAGE(S) MAXIMUM PREMIUM DISCOUNT TAX TOTAL
COVERAGE take note of all exclusions.
Emergency Medical Care 50 000 76.07 0.00 0.00 76.07
(Deductible : $0) In the event of hospitalization
or medical consultation, you
TOTAL PREMIUM 76.07 0.00 0.00 $76.07
must contact BLUE CROSS
PAID BY: Visa TOTAL PREMIUM: $76.07 TRAVEL ASSISTANCE
AUTHORIZATION NUMBER: 025410 AMOUNT PAID TO DATE: $76.07 IMMEDIATELY. Failure to do so
PAYER'S NAME: Tara Hendrycks may result in REFUSAL of your
claims.
PAYMENT AMOUNT: $76.07 BALANCE: $0.00

Waiting period: Your insurance contract includes a 3-day waiting period as of the date of purchase, during which BON VOYAGE !
the insured persons are covered only in case of accident and injury. During this waiting period, the insured
persons are not covered in case of illness.

TRAVEL INSURANCE TRAVEL ASSISTANCE

Canada / USA Mexico
PRINCIPAL INSURED
1-800-361-6068 800 062-3174
Youssef Ouchhoutta
Elsewhere Dominican Rep.
CONTRACT 1-800-7328-7473 1-800-203-9666
DL80695 Collect
514-286-8411
Contract Extension:
Canada / USA In the event of hospitalization or medical consultation, you must contact BLUE CROSS
1-877-986-7681 or 514-286-7681 TRAVEL ASSISTANCE IMMEDIATELY. Failure to do so may result in REFUSAL of your claims.
The sponsor, mentioned below, certifies having answered the questions regarding pre-existing conditions on behalf of all covered persons
and has agreed to communicate all relevant information regarding the insurance to them.

Sponsor's name: Christa Vernier Relationship to the primary insured: Employer

Health declaration

Insurance eligibility
Insurance eligibility has been determined according to the answers provided to the following questions. Please read them carefully and
advise us immediately of any error. The answers must be valid for each person insured under the contract.
1. Has your doctor advised you not to travel? No
2. Do you suffer from a terminal illness? No
3. Do you suffer from kidney failure treated through dialysis? No
4. In your life, have you ever been diagnosed with or treated for metastatic cancer? No
5. In the past 12 months, have you been diagnosed with, had treatments or taken medication for cancer (with the exception of basal No
cell carcinoma)?
6. Do you suffer from heart failure or cardiomyopathy? No
7. Are you waiting for an organ transplant for one or several of the following: kidneys, lungs, liver, heart, bone marrow, pancreas? No
8. In the past 24 months, have you used home oxygen or taken cortisone pills for a pulmonary condition? No

Exclusions relating to pre-existing conditions

The contract contains exclusions relating to pre-existing conditions.
1. If a covered person has already undergone one of the procedures mentioned below, or has already suffered * or is currently
suffering from one of the following cardiovascular conditions, all of the cardiovascular conditions listed will not be covered: bypass,
angioplasty, defibrillator, heart attack, aortic aneurysm, angina, valvular heart disease, peripheral vascular disease, heart rhythm
disorders (arrhythmia, tachycardia, bradycardia).
2. If one of the covered persons has had a stroke (cerebrovascular accident) or TIA (transient ischemic attack), both of these
neurological conditions are not covered.
3. If one of the covered persons has already suffered * or is currently suffering from one of the following conditions, all of the
pulmonary conditions listed are not covered: chronic bronchitis, emphysema, cystic fibrosis, COPD (chronic obstructive pulmonary
disease).
*By suffered, we mean having undergone a procedure, consulted a doctor, been diagnosed, treated, hospitalized, or have been prescribed or taken medication in connection
with one of the conditions listed, or that a doctor recommended that you receive treatment, be tested, take medication or undergo a procedure linked to one of these
conditions. Having ignored symptoms that can lead to one of these conditions also constitutes grounds for exclusion.

B) Other exclusions due to pre-existing medical conditions

All medical conditions other than the ones stipulated above are subject to the following notice regarding pre-existing conditions:
Notice regarding pre-existing medical conditions
For an existing illness, injury or health issue to be covered during a trip, the pre-existing medical condition must be stable during the 3
months prior to the effective date of coverage.

For a pre-existing medical condition to be considered stable, it must meet all the following criteria:
1. No new medical diagnosis has been made
2. No new symptoms appeared and there was no worsening or increase in the frequency of existing symptoms
3. No hospitalization has taken place
4. No new medication was prescribed or recommended
5. No change of dosage was made to a medication already prescribed or recommended (dose increased or decreased, or
consumption stopped)
6. No new treatment or medical test is pending or has been prescribed, ongoing or recommended
7. No ongoing treatment has been changed or discontinued
8. No prescribed or recommended treatment, nor medical advice has been ignored
9. Not have required the use of nitroglycerin for any heart condition

Client answer: You have been informed of the previous clauses and have stated that you understand them. Otherwise, you must contact the
distributor or the insurer.
 Please note that this insurance contains OTHER EXCLUSIONS which are detailed in the Visitors to Canada Insurance Policy. In addition,
please note that any fraudulent, deceptive or exaggerated statement or claim will render the travel insurance contract NULL and VOID.

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 Garantie Soins médicaux d'urgence - frais en lien avec la COVID-19
Below is how your Blue Cross® travel insurance covers your emergency medical care in the event of a COVID-19 infection.

Emergency Medical Care benefit protects you from the financial implications that may arise from certain medical services or care you receive
during your stay in Canada as well as during side trips taken outside of Canada during the period of coverage.

Each insured person under the contract is insured up to the amount of coverage shown on the first page of your insurance certificate. All
amounts in the contract are in Canadian dollars.

Emergency medical care received while travelling and related to COVID-19 is covered, subject to exclusions due to pre-existing conditions
provided for in the contract

Eligible treatments are those declared urgent and necessary to stabilize the insured person's medical condition.

If you contract COVID-19 during the period of coverage, the Emergency Medical Care benefit insures primarily the following costs:

● Hospitalization costs in a semi-private room, physician fees, the cost of purchasing prescribed medication as part of an emergency
treatment and the cost of tests and diagnostics.

● Repatriation costs to the country of permanent residence of the insured person when approved by Blue Cross Travel Assistance and
ambulance transportation expenses.

● Subsistence allowance up to a maximum of CAD 1,500, including accommodation costs at the destination if the insured person
cannot return because they have been placed under quarantine.

Please note that a positive COVID-19 test result when a person has no symptoms or if their condition does not require emergency medical
treatment or hospitalization does not constitute a medical emergency within the meaning of that contract. In this case, the costs mentioned
above are not covered by the insurer even if the person was placed under quarantine.

Also excluded are tests that are not required because of a medical emergency, such as PCR tests for COVID-19 sometimes required upon
boarding.

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