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

Activities of daily living
means eating, bathing, using the toilet, changing positions (including getting in and out of a bed or chair) and dressing.
Artery or vein disorder
includes aneurysm, peripheral vascular disease (PVD), deep vein thrombosis (DVT), thrombophlebitis, phlebitis, blood clots, venous insufficiency, carotid artery stenosis, arteriosclerosis, varicose veins.
Heart condition
includes heart attack (myocardial infarction), arrhythmia, atrial fibrillation, heart murmur, irregular heart rate or beat, chest pain or angina, arteriosclerosis, aneurysm, carotid artery occlusion, (congestive) heart failure, cardiomyopathy, heart by-pass operation, valve surgery (repair or replacement), valvuloplasty or any other kind of heart surgery, angioplasty, use of pacemaker or defibrillator, congenital heart defect or any other condition relating to the heart or blood vessels.
Heart surgery
includes heart bypass operation, angioplasty, valve replacement (repair or replacement), valvuloplasty, implanted pacemaker, implanted defibrillator.
Lung condition
includes chronic obstructive pulmonary disease (COPD), bronchial asthma, asthma, chronic bronchitis, emphysema, tuberculosis, pulmonary fibrosis.
Major organ
includes heart, kidney, liver, or lung.
Medical consultation
means any medical services obtained from a licensed medical practitioner for a sickness, injury or medical condition, including but not limited to any or all of: history taking, medical examination, investigative testing, advice or treatment, and during which a diagnosis of the condition need not have been definitively made. This does not include regular medical check-ups where no medical signs or symptoms existed between check-ups or were found during the check-up.
Signs or symptoms
means any evidence of disease experienced by you or recognized through observation.
Stability period
is the 365 days immediately before the effective date.
Terminal
applies to a medical condition for which a physician gave a prognosis of eventual death or for which palliative care was received prior to the effective date.
Treatment
means a medical, therapeutic or diagnostic procedure prescribed, performed or recommended by a physician including, but not limited to, prescribed medication, investigative testing or surgery.