2021/09/09

Policy Number: SGA-13136578

Elizabeth Allen
303-1580 MARTIN ST
WHITE ROCK BC V4B5M3 CA

Hello Elizabeth Allen,

Thank you for purchasing and entrusting your travel insurance with us!

Your travel insurance policy has been set up. Included in the confirmation you will find the details related to your
customized policy. Please review ALL the information and should you believe something is inaccurate
contact me at 888-831-9338 to discuss. If all of the information is correct and a signature is required, please sign
and send back. This signed document may be required if you have a claim. No signature on file may result in a
potential non-payment of claim so please make sure to get this back PRIOR to departure.

Do you have CHANGES?

Should you have a change in your health (including a change in medication dosage) or travel dates, it is very
important you consult your policy wording along with your confirmation of insurance to confirm your eligibility
and stability. Should you not be eligible or stable you could potential be traveling without coverage.

Not travelling any more, leaving on a different date or have to come home earlier than expected? Make sure to
contact me to review your file and make sure your policy reflects these changes.

Have to make a CLAIM?

You must make every effort to call the emergency assistance prior to receiving any treatment for any and all
medical emergency during your trip. Should you fail to call Emergency assistance to obtain prior authorization,
your benefits may be significantly limited (see the policy for more details). To open a claim, please call 1-888-669-
0135 (calling within North America) or call collect 519-251-0135 or email northbridgeassistance@acmtravel.ca.

Safe travels,

Bailey Bourre
Travel Guardian Insurance
 2021/09/09

Policy Number: SGA-13136578

LETTER OF CONFIRMATION
(RECEIPT OF INSURANCE)

Allen, Elizabeth 303-1580 MARTIN ST

604-385-0214 WHITE ROCK BC V4B5M3 CA
bailey.b@travelguardian.ca

INSURED & POLICY INFORMATION

INSURED: CATEGORY: PRE-EXISTING CONDITION: DEDUCTIBLE:

1. Elizabeth, Allen - 1948/05/27 (73) Rate category 2 365 days stable $250.00 USD

TRIP INFORMATION

DEPARTURE DATE: 2021/11/22 INSURANCE PLAN: True Senior Guard

EFFECTIVE DATE: 2021/11/22 INSURANCE CATEGORY: 31 days multi-trip
EXPIRY DATE: 2022/11/21

PREMIUM DETAILS

PAYMENT DATE: 2021/11/22 PREMIUM TOTAL: $387.72

METHOD OF PAYMENT: Credit Card ADMINISTRATION FEE: $0.00
CARD HOLDER NAME: Elizabeth Allen PREMIUM CHARGED: $387.72
CARD NUMBER: **** **** **** 7518 AUTHORIZATION #: CHJFRJKZDV

This is your confirmation and tax receipt. If any of the information is not correct, please call 888-831-9338 or email
bailey.b@travelguardian.ca. You may cancel this policy within 10 days of the date of purchase for a full refund, provided it is before the
Effective Date of your policy. Please also note that this is not your policy wording. Refer to the policy wording for complete details of your
insurance.
 2021/09/09

Policy Number: SGA-13136578

PERSONALIZED MEDICAL CONFIRMATION PAGE

Eligibility:
You must meet the following eligibility requirements on the departure date of each trip in order to be eligible for coverage.
Coverage is NOT AVAILABLE to any individual who:

1. is travelling against the advice of a physician or knows of any reason to seek consultation during the period of coverage; or
2. has a life expectancy of 6 months or less

Are all applicant's eligible?

☑ Yes ☐ No

Rate Qualification:
2. At the time of application, how many medications* in total do you take or been ordered to take by a physician to treat one or more of the following
conditions:
a. Heart condition(s)/disease (do not include aspirin, high blood pressure or cholesterol medications)
b. Lung condition(s)/disease (EXCLUDING asthma and/or seasonal allergies, INCLUDING home oxygen)
c. Diabetes (treated with oral medications or insulin)
d. Stroke and/or transient ischemic attack (mini-stroke, TIA)
Applicant 1
3 or more medications ☐
2 medications ☐
1 medication or none ☑
3. At the time of application, are you being treated**, taking or have been prescribed medication for any of the following (including Aspirin or Entrophen):
AIDS or HIV Bowel obstruction or bowel surgery
Cancer (excluding basal cell/squamous cell skin cancer) Cholesterol
Crohn's disease Dementia and/or Alzheimer's
Diabetes (treated with oral medications or insulin) Fibromyalgia
Gastrointestinal bleeding High Blood Pressure (HBP)
Heart condition(s)/disease (INCLUDING aspirin) Kidney disease (INCLUDING kidney stones & dialysis)
Liver disease Lung condition(s)/disease (INCLUDING asthma and/or seasonal allergies)
Pancreatic disease Parkinson's disease
Seizures Spleen disease
Stroke (CVA) and/or mini-stroke (TIA) (INCLUDING aspirin) Ulcerative colitis
Applicant 1
4 or more medical conditions ☐
3 medical conditions ☐
2 medical conditions ☐
1 medical condition ☑
None ☐
4. Has it been longer than 12 months since you last saw a doctor or nurse practitioner and/or have you used tobacco products in the last 2 years?
Applicant 1: ☐ Yes ☐ No
5. Would you like to increase your epidemic or pandemic coverage amount including but not limited to COVID19 coverage from $200 thousand to $2
million?
Applicant 1: ☑ Yes ☐ No
6. Most frequently visited country
Applicant 1: United Arab Emirates
7. State
Applicant 1: N/A
Applicant 1 qualifies for rate category 2.

Signature of Applicant: Elizabeth Allen Date of Signature:

 2021/09/09

Policy Number: SGA-13136578

WALLET CARD
In the event of an emergency, you must call 1 888 669 0135 toll-free from Canada or the U.S. or +1 (519) 251 0135 collect from anywhere else immediately.
Please note that if you do not call the Emergency Assistance Company in an emergency and prior to treatment, you will have to pay 30% of the eligible
medical expenses we would normally pay under this policy. If it is medically impossible for you to call, please have someone call on your behalf.

Insured: Elizabeth, Allen If you are in need of any medical attention, contact our
Assistance Centre immediately.
Policy Number: SGA-13136578-1
Deductible: $250.00 USD Canada & US 1-888-669-0135
Effective Date: 2021/11/22 Anywhere else (collect) 1-519-251-0135
Expiry Date: 2022/11/21 Assistance Company (ACM)
P.O. Box 337, Station A
Windsor, ON N9A 6K7