Application form. Application form Mediflex. 1. Policy holder. 3. Desired coverage. 4. Deductible. 5. Inception date of the insurance

Transcription

1 Application form Mediflex Broker: Please complete and check where applicabl Policy number: Application form 1. Policy holder Name and first names (in full) Address Residence Telephone number Date of birth f. Gender Identity number Occupation Type of business Employer k. Legal person 2. Which island does the person to be insured depend on in case of hospitalization and nursing? (the applicant must be a resident of, and also live in, the countries Curaçao, Sint Maarten and the BES Islands) 3. Desired coverage 4. Deductible 5. Inception date of the insurance 6. Premium payment 1. f. male female k. yes no 2. Curaçao Bonaire St. Eustatius St. Maarten Saba mediflex alternative cure spectacle glasses and contact lenses dentist (recent dental record to be submitted) 5. Date: renewed each year for one continuous year 6. ANG 250,- ANG 500,- ANG 1.000,- yearly half yearly quarterly monthly 7. Current insurance Are any persons to be insured already insured for medical benefits? If so, state nam At which company or agency? Under what type of insurance? Are all family members included in this insurance If not, whom not and why? 7. yes no Name: Name company/agency: yes no

2 Health Statements (to be completed by the prospect(s) or their parents). Please give answers, do not cross out! Benefits insured Class Class Class Class Class 1. Name and first name(s) of person(s) to be insured (in full) 2. Identification number 3. Sex male female male female male female male female male female 4. What is your occupation? 5. Is diving your profession? 6. What is your height and weight? cm. k cm. k cm. k cm. k cm. k 7. What is the strength of your spectacles and/or L. R. L. R. L. R. L. R. L. R. your contact lense(s)? 8. Do you ride a motorcycle? How many cc? 9. Please state name of your family physican (no pediatrician). Was this your family physican for the past three years? If no, please state name of your previous physican. 10. Do you have any complaints concerning your health at the present time? (explain overleaf if necessary) 11. Have you had any complaints in the past three years for which you did or did not consult a physican? Please provide details. 12. Mention ailments, malformations and other (birth-)defects, if any? 13. Have you ever been admitted to a hospital, sanatorium or psychiatric institution, or any other institution? If so where, when, for how long and for what reason? 14. Have you ever been treated by a specialist? If so by whom, where, when, for how long and for what reason? Fully recuperated? 15. Has your blood ever been tested, for instance for anemia, diabetes, kidney disease, cholesterol, jaundice (hepatitis A or B), sexually transmitted diseases such as syphilis or AIDS? 16. Have you taken any medication in the past three years?

3 If so, which medicines? 17. Do you drink alcohol? If yes, how much? a. Do you smoke? If yes, how much per day? b. Do you take drugs? If so, what kind and how much? c. 18. When did you last consult a dentist? 19. Have any of the persons to be insured suffered from one of the following illnesses? If so, which illness, when, name of the attending physician and duration of treatment. Nervous disorders or mental illnesses, being overworked, a. serious headaches, migraines et Hay fever or other allergies b. Eye diseases or ear diseases c. Eczema, psoriasis or other skin diseases d. Back troubles such as hernia, sciatica, lumbago e. f. Neuritis, Parkinson s disease f. f. f. f. f. Diseases of the muscular and skeletal system, diseases g. of the joints, musclar disorders, knee, shoulder or neck complaints (including rheumatic ones) Varicose veins, crural (leg) ulcers, or thrombosis h. Diseases of the lungs or the bronchial tubes,. including asthma, pleurisy, bronchitis etc Cardiovascular diseases (high blood pressure).. Constriction or heart attack, heart rushing, or heart region k. Thyroid problems k. k. k. k. k. l. Diseases of the stomach (ulcer), intestines (chronic diarrhea), gall bladder or liver (hepatitis) l. l. l. l.. m. Diabetes m. m. m. m. m. n. Diseases of the kidneys, urinary tract, bladder or genitals. n. n. n. n. n. And for men: any prostate problems? o. Any other illnesses or accidents not mentioned here o. o. o. o. o. 20. For women only: Are you pregnant? a. Are you under the care of a gynaecologist? b. If so, give further details. Did you have any complications during previous pregnancies? c. Did the pregnancy or delivery have any permanent d. unfavourable effects? Are there any malformations of the breast or cyst problems? e. I hereby give my consent to the medical adviser of Guardian Group Signature: Signature: Signature: Signature: Signature: to ask for any additional information on the condition of my health from the general practitioner or specialist. Completed truthfully. i j l

4 8. Previous insuranc Has any company ever refused, terminated or imposed more severe conditions for a medical insurance of any of the persons to be insured? If so, which of the persons and by which company? Please state details. Who was your previous insurer? Where were you insured the past 5 years? Who was your family physician? (if applicable, please state several physicians) 8. yes no Name: Name company: 9. Criminal record Have you, or any of the persons to be insured had a criminal record in the past eight years? If so, please provide details. 9. yes no 10. Further information Are there any circumstances which may be material for the company for the evaluation of the risk? If so, please explain. 10. yes no The undersigned guarantees the correctness of the information given and certifies that no relevant information for the evaluation and acceptance of this insurance has been withhel He or she agrees to the premium, and also to the conditions that are in effect for this insuranc Date: Signature contracting party: Premium calculation: Mediflex Alternative cure Dentist Spectacle and contact lenses Total annual premium Note: when calculating the premium please take into consideration, possible age and/or weight surcharg Details: This translation has been issued for the convenience of our English speaking customers. The contract is exclusively governed by the Dutch wording of the policy.

5 Ascertaining and verifying your identity Within the framework of national and international legislation and regulations, such as the prevention of money laundering and fi nancing of terrorism and the Offi ce for the Disclosure of Unusual Transactions, Guardian Group, and its affi liated companies such as Fatum Holding N.V., Fatum General Insurance N.V., Fatum General Insurance Aruba N.V., Fatum Health N.V., Fatum Life N.V. and Fatum Life Aruba N.V. (hereinafter referred to as: Guardian Group ), in its capacity of insurer (fi nancial service provider), is obliged to verify your identity. This enables us to establish whether the identity you have given us matches your true identity. The aforesaid means that Guardian Group will ask you, regardless of you being a private or business client, to identify yourself by means of valid ID/original documents, prior to providing you with a service or entering into a business relationship with you. Subsequently, Guardian Group will make clear (color) copies of your valid ID/original documents and arrange for you to sign and date these copies. These copies are deemed to form an integral part of your request and will be fi led in the dossier held by Guardian Group, together with this form. Any personal data will be stored by us in the Guardian Group client administration. The various regulators will ensure that Guardian Group, in its capacity of insurer and fi nancial service provider, will correctly and properly meet and fulfi ll its statutory obligations with regard to ascertaining and verifying your identity and, if (legally) required, the disclosure of personal data to third parties. The applicable diagram below is to be completed by a Guardian Group staff member or a Guardian Group intermediary. Valid IDs in the event of natural persons and/or executive legal persons* Policyholder Insured Premium contributor Beneficiary Number Rnwl date Number Rnwl date Number Rnwl date Number Rnwl date ID card (sédula) or Driver license or Passport (*) A copy of an (expired) ID card (sédula), driver license or passport is not accepted as valid ID. Original documents in the event of legal entities Policyholder Insured Premium contributor Beneficiary a) Extract from the Commercial Register of the Chamber of Commerce** and, among other things, b and c: b) Articles of Association and c) Shareholders register Yes/no Yes/no Yes/no Yes/no Yes/no Yes/no Yes/no Yes/no Yes/no Yes/no Yes/no Yes/no (**) A copy of an extract for the Commercial Register of the Chamber of Commerce and/or older than six (6) months is not accepted as an original document. (Yes/no) Delete as appropriat To be completed by a Guardian Group staff member or a Guardian Group intermediary: I (full surname and fi rst name of Guardian Group staff member or Guardian Group intermediary***), herewith declare that I have accepted the original and valid ID/original documents referred to by me in the above diagrams, and that I have made clear (color) copies from these, which copies are deemed to form an integral part of the client s request and which will be added by me to the Guardian Group dossier. Country : Date : Signature : (***) Delete as appropriat

6 ARUBA L.G. Smith Boulevard 162 P.O. Box 510 Aruba Tel.: (297) Fax: (297) BONAIRE Kaya Gobernador N. Debrot 35 P.O. Box 152 Bonaire Tel.: (599) Fax: (599) CURAÇAO Cas Coraweg 2 P.O. Box 3002 Curaçao Tel.: (599-9) Fax: (599-9) SINT MAARTEN A.J.C. Brouwers Road 6 P.O. Box 201 Sint Maarten Tel.: (1-721) Fax: (1-721)