Fax this Application Form to:

Transcription

1 Requirements before submitting this application form: 1. Please complete the Medical Health Declaration section on this Application Form. 2. Please read and sign the Declaration at the bottom of the Application. 3. You must advise us if there is anything that you are aware of that may affect us granting you insurance. 4. The Main Applicant can complete this application on behalf of his/her spouse and children. Note: If more than three children, complete a second application form and also show Main Applicant name. I N S U R E D P E R S O N ( S ) : Main Applicant ( Mr. Mrs. Ms. Miss.) Spouse / Partner ( Mr. Mrs. Ms. Miss.) Surname : Surname : First Name : First Name : day/month/yr day/month/yr : Occupation : Occupation : Home Country i.e. The country for which you hold a passport Home Country i.e. The country for which you hold a passport Dependent Children (Please indicate Male or Female) Surname First Name Day Month Year Gender C O N T A C T D E T A I L S : Current Residential Address* Business (Employer) Details * All correspondence will be sent to this address unless otherwise notified Company Name : Address : Address : : : Province : Province : Postal Code : Postal Code : Country : Country : Home : Ph. : ( ) Work: Ph.: ( ) Fax : ( ) Fax ( ) Mobile : E M E R G E N C Y C O N T A C T : Next of Kin or emergency contact name : Relationship to Main Applicant : Ph. : O T H E R D E T A I L S : How long have you lived in Thailand? : (months) (years) And how long do you intend remain in Thailand? : (months) (years) iestimate only Have you ever had medical insurance? : Yes No If yes, please provide name of insurance company

2 M E D I C A L H E A L T H D E C L A R A T I O N : Have any of the persons applying for Cover had any symptoms or treatment for any of the following conditions in the last two years prior to this application? If Yes, please list the condition(s) and dates under the appropriate person. If No, please tick ( ) No. Height Weight Main Applicant Spouse/Partner Ears, Eyes, Nose, Throat, Teeth Yes No Yes No Gall Bladder, Liver or Pancreas Yes No Yes No Stomach or Oesophagus Yes No Yes No Heart Related Conditions Yes No Yes No Vascular System Yes No Yes No Cerebrovascular / Stroke / TIA Yes No Yes No Psychiatric / Psychological Yes No Yes No Chronic Conditions Yes No Yes No Congenital / Birth Conditions Yes No Yes No Cancer or Related Conditions Yes No Yes No Kidney, Bladder, Bowel, Prostate, Diabetes Yes No Yes No Respiratory (including Asthma) Yes No Yes No Reproductive Systems Yes No Yes No Skeletal / Joints Conditions Yes No Yes No Injuries / Hospitalization Yes No Yes No Neurological Yes No Yes No Blood Pressure / Hypertension Yes No Yes No Any other Conditions? If YES, State Condition: Yes No Yes No Main Applicant: Spouse: cm Kg cm Kg Is there any family history relating to any of the above conditions? No Yes (If YES, please give details) Please provide details of your (family) doctor(s) who has/have treated you/your family in the last 2 years Name : Address : Phone : ( ) Fax : ( )

3 M E D I C A L H E A L T H D E C L A R A T I O N : Have any of the persons applying for Cover had any symptoms or treatment for any of the following conditions in the last two years prior to this application? If Yes, please list the condition(s) and dates under the appropriate person. If No, please tick ( ) No. Height Weight Child 1 Child 2 Child 3 cm cm cm Kg Kg Kg Ears, Eyes, Nose, Throat, Teeth Yes No Yes No Yes No Gall Bladder, Liver or Pancreas Yes No Yes No Yes No Stomach or Oesophagus Yes No Yes No Yes No Heart Related Conditions Yes No Yes No Yes No Vascular System Yes No Yes No Yes No Cerebrovascular / Stroke / TIA Yes No Yes No Yes No Psychiatric / Psychological Yes No Yes No Yes No Chronic Conditions Yes No Yes No Yes No Congenital / Birth Conditions Yes No Yes No Yes No Cancer or Related Conditions Yes No Yes No Yes No Kidney, Bladder, Bowel, Prostate, Diabetes Yes No Yes No Yes No Respiratory (including Asthma) Yes No Yes No Yes No Reproductive Systems Yes No Yes No Yes No Skeletal / Joints Conditions Yes No Yes No Yes No Injuries / Hospitalization Yes No Yes No Yes No Neurological Yes No Yes No Yes No Blood Pressure / Hypertension Yes No Yes No Yes No Any other Conditions? If YES, State Condition: Yes No Yes No Yes No Child 1: Child 2: Child 3: Is there any family history relating to any of the above conditions? No Yes (If YES, please give details) Please provide details of your (family) doctor(s) who has/have treated you/your family in the last 2 years Name : Address : Phone : ( ) Fax : ( )

4 C O M M E N C E M E N T D A T E O F P O L I C Y : Start Insurance On (Day/Month/Year) : (Subject to acceptance and receipt of the premium by NZI- InterGlobal Healthcare) P L A N S E L E C T I O N (please tick as appropriate): ELITE (NIL EXCESS ONLY) PLUS COMPREHENSIVE SELECT STANDARD O U T P A T I E N T E X C E S S S E L E C T I O N applicable to Plus, Comprehensive, Select Plan only. (please tick as appropriate): THB 1,800 (See Table A Premium) NIL (See Table B Premium) I N P A T I E N T & O U T P A T I E N T E X C E S S S E L E C T I O N applicable to Plus, Comprehensive, Select Plan only. (please tick as appropriate): NIL THB 3,400 THB 6,800 THB 17,000 THB 34,000 THB 68,000 THB 170,000 THB 340,000 I N P A T I E N T E X C E S S S E L E C T I O N applicable to Standard Plan only. (please tick as appropriate): NIL THB 34,000 THB 68,000 THB 170,000 THB 340,000 O P T I O N A L A D D - O N P L A N S (please tick as appropriate): MATERNITY NIL CO-INSURANCE PERSONAL ACCIDENT 1 UNIT PERSONAL TRAVEL MATERNITY 10% CO-INSURANCE PERSONAL ACCIDENT 2 UNITS MATERNITY 20% CO-INSURANCE PERSONAL ACCIDENT 3 UNITS PERSONAL ACCIDENT 4 UNITS PERSONAL ACCIDENT 5 UNITS Payment Method: Cash Credit card (please attach completed credit card payment form) Cheque Bank Transfer (bank account details below) BANK TYPE ACCOUNT NAME ACCOUNT NUMBER BRANCH BANGKOK BANK SAVINGS SAFETY INSURANCEPUBLIC COMPANY SIAM COMMERCIAL SAVINGS SAFETY INSURANCEPUBLIC COMPANY KASIKORN BANK SAVINGS SAFETY INSURANCEPUBLIC COMPANY VANICH TOWER BRANCH THANAPOOM TOWER SUB. BRANCH RATCHADAMRI BRANCH Declaration: To be signed by the Main Applicant on behalf of all persons to be insured: 1. I apply for the Safety Insurance Public Company Limited, InterGlobal Healthcare Insurance and I declare that to the best of my knowledge and belief that all information given in the Application Form and the Medical Declaration are true and accurate statement and that I have not omitted any details pertinent to this application. 2. I acknowledge that Safety Insurance Public Company Limited, do not cover any pre-existing conditions unless transferring from another plan, when this is then subject to the discretion of Safety Insurance Public Company Limited. 3. It is agreed that the information given above, forms the contract between Me and Safety Insurance Public Company Limited. 4. I have read and understood the most recent copy of the Safety Insurance Public Company Limited, InterGlobal Healthcare Insurance Policy and that the information contained therein supersedes any previous version of the Policy and any other verbal interpretations of the Policy terms and conditions. 5. I understand that if I am not satisfied with the Safety Insurance Public Company Limited, InterGlobal Healthcare Insurance Policy that I can return the Policy, Certificate and Assistance Card within 30 days of receipt and have a full refund of premium paid provided that I have not and will not make a claim. 6. I agree to provide Safety Insurance Public Company Limited, or their representative with any relevant information regarding current or past medical insurance claims and that Safety Insurance Public Company Limited, or their Representative may release claims information to any other party. Consent to Release Medical Information I authorise any hospital, medical centre, doctor, practitioner, physician or specialist who has treated me or any person stated on this application form, to release all information in relation to such treatment and any known medical history to Safety Insurance Public Company Limited, or their agents or representatives, to assist with the processing of this application form and any subsequent claims. Signature Day Month Year Main Applicant Date: I M P O R T A N T N O T E : P U R S U A N T T O S E C T I O N O F T H E C I V I L C O D E, Y O U A R E T O D I S C L O S E I N T H E A P P L I C A T I O N F O R M, F U L L Y A N D F A I T H F U L L Y, A L L T H E F A C T S Y O U K N O W O R O U G H T T O K N O W, O T H E R W I S E T H E P O L I C Y I S S U E D H E R E U N D E R M A Y B E V O I D.

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