SRMRM/RSMRM

MRM Special Risks Inc.

Risques Spéciaux MRM Inc. MGA TPA

Tel:
1-877-385-2177
E-mail:
[email protected]

PRE-EXISTING CONDITIONS ARE NOT COVERED WITH THIS APPLICATION.

I confirm that I have followed the instructions set out below:

  1. I have reviewed my answer to each question to ensure that I have answered each question truthfully, accurately and completely so that SRMRM can accurately calculate premium appropriate for my health status,
  2. I selected the number of medications that I am taking for each medical condition (be sure the total number of medications that you are taking is correct) and then
  3. I selected the period my medical condition has been Stable since the last occurrence of any new or change in symptom, investigation, consultation, new or change in medication, new or change in Treatment, or Hospitalization that I had for each condition.

Key Terms Used in this Application