CARE & HEALTH. Application Form CARE & HEALTH. APPLICATION FORM

Transcription

1 CARE & HEALTH Application Form CARE & HEALTH. APPLICATION FORM 2

2 Your details Last name First name Date of birth / / (dd/mm/yyyy) Nationality Gender (M/F) Residential address (1) City Country Postcode Mailing address (if different from above) City Country Postcode Phone number Mobile (2) (2) Occupation Dependants to be included in the plan Relationship (eg: Spouse, Child) Last name First name Date of birth (dd/mm/yyyy) Gender (M/F) Country of Usual Residence (1) / / / / / / / / (1) Any country in which you and your dependants will reside for at least 6 months of the year is called Country of Usual Residence. (2)We can send you confirmation by SMS of any hospital guarantee we issue if you provide us with your mobile phone number. An address, however, must be provided as we will send invoices and claim statements by . Payment How would you like to pay your premium? Annually Semi-annually Quarterly (Semi-annual and Quarterly premiums are subject to a 3% loading) Select your method of payment: Visa / MasterCard (For payment by credit card, upon receipt of your invoice, go to log into your secure personal access page and register your credit card details online) Bank Transfer (Account details for transfer will be provided with your invoice) Effective date of coverage When would you like your cover to start? / / dd mm yyyy Your membership and that of your dependants are effective on the date indicated on your Certificate of Enrollment, and at the earliest on the day after we receive the Application Form and Health Declaration Form duly filled and signed, along with all requested additional information, subject to approval by HENNER - GMC Medical Advisory Board and payment of first premium. 1 CARE & HEALTH. APPLICATION FORM

3 Choose your Area of Coverage Area 1 Area 2 Area 3 Area 4 Area 5 Brazil, Hong Kong, Mainland China, Switzerland + countries in areas 2, 3, 4, and 5. Argentina, Australia, Belarus, Bosnia, Canada, Colombia, Ireland, Israel, Italy, Japan, Macao, Mexico, Monaco, Russia, Singapore, South Korea, Spain, United Kingdom, Venezuela + countries in areas 3,4,and 5. Belgium, Chile, Denmark, Finland, France, Germany, Greece, Hungary, Iceland, New Caledonia, New Zealand, Portugal, South Africa, Sweden, Rest of Latin America, Rest of Europe + countries in areas 4,and 5. Bahrain, Egypt, Iran, Iraq, Jordan, Kuwait, Lebanon, Morocco, Oman, Qatar, Saudi Arabia, Syria, Tunisia, Turkey, United Arab Emirates, Yemen Rest of Middle East + countries in area 5. Rest of Africa, Rest of Asia (Bangladesh, Cambodia, India, Indonesia, Laos, Malaysia, Mongolia, Myanmar, rth Korea, Philippines, Sri Lanka, Thailand, Vietnam, etc). You will be covered outside your chosen Area of cover for unexpected illnesses and accidents only. Assistance Companies evacuate to the nearest place of suitable care so make certain the country to which you might be evacuated to is in your chosen Area of Cover so that hospitalization costs are covered after any evacuation. Choose your Plan PREMIUMS Primary Vitality Serenity Prestige 1 Choose your Maximum Annual Limit: US$ 200,000 US$ 300,000 US$ 500,000 US$ 4,500,000 2 Choose your level of coverage for Outpatient benefits: (it will also apply to Maternity, Dental & Vision of chosen) 80% of usual 90% of usual 100% of usual benefits benefits benefits Emergency Assistance, Repatriation & Evacuation and Personal Liability* are included. * t available in every country. Choose your Options Maternity * t available with Primary Dental * t available with Primary Vision Only available if Dental is also chosen Choose your Life Insurance Death (all causes) or Permanent Total Disability Select your lump sum benefit: US$ 25,000 US$ 50,000 US$ 100,000 US$ Optional double benefit when death is caused by accident (1) Your Death (all causes) or Permanent Total Disability lump sum multiplied by 2. (1)Only available if Death (all causes) or Permanent Total Disability is chosen. * t available with Primary or Vitality Total annual premium including all dependants TOTAL US$ / year CARE & HEALTH. APPLICATION FORM 2

4 R.C.S. PARIS B ref GMCG /2013 Your declaration I, the undersigned, certify that the information filled in the present Application Form, as well as in the Health Declaration Form, is correct and sincere, and certify not having declared or withheld any information which might affect the risk assessment. I understand and have taken note that any false declaration or non-disclosure will void coverage under this policy, that in this case the insurer would retain paid premiums as civil damages and that me and my dependants shall have to reimburse perceived benefits. I hereby request to become a member of La Garantie Médicale et Chirurgicale (GMC), under the Care & Health insurance plan designed by HENNER and underwritten by La GMC. I acknowledge that I have read and understood the guarantees described in the table of benefits and the General Conditions of the Care & Health Policy provided with this Application Form. I have duly noted that my enrollment under the Care & Health Policy shall be effective subject to: Approval by the HENNER - GMC Medical Advisory Board of the enclosed health declaration duly filled out by myself and all my dependants who have reached majority Payment of premium In the event of my death, I appoint as beneficiary my surviving spouse unless legally separated; otherwise in equal shares my children born or to be born, the share of a deceased child going to his/her own children or to his/her brothers and sisters if he/she has no children; otherwise in equal shares my surviving parents; or in their absence, my heirs. I further note that should I wish to change beneficiaries at any time, I shall write formally to HENNER - GMC with details of the requested changes and clearly identify any new beneficiaries. Signed in (city; country) Policy holder s signature, precede by «read and agreed» : On (date) / / (dd/mm/yyyy) Your declaration To apply for cover, you need to complete this Application Form and the Health Declaration Form. We would like to draw your attention to the fact that the health declaration has to be sent directly to our Medical Board (by or by post using a separated envelope) at the following address: Medical board (Care & Health Application) GMC Services Asia Pacific 20 Cecil Street, #05-04/05/08 Equity Plaza Singapore health.declaration@henner.com For the other documents, you can scan your signed forms and them to us at hennerpro.asia@henner.com When submitting, remember also to include: Your bank account details, for reimbursement of claims A copy of your ID or passport The Certificate of Insurance from your last insurer, if you would like us to consider waiving some of the usual waiting periods If your Application is accepted we will send you a Premium Invoice and your Policy will not be in force until that premium is paid. Please make sure to answer all questions and to sign the forms. We look forward to being of service. HENNER - Simplified private joint stock company - Registered capital of 8,212,500 - RCS Paris B TVA intra communautaire FR ORIAS (available at - Regulated by the ACP (Prudential Supervisory Authority) - ISO 9001 certified by Bureau Veritas Certification Certificate Headquarters: 10 rue Henner Paris Cedex 09 France - Hauteville Insurance Company Limited, Harbour Court - Les Amballes, St. Peter Port, GUERNSEY GY1 4QA - CHANNEL ISLANDS Licensed by the Guernsey Financial Services Commission Registered Number : La Garantie Médicale et Chirurgicale Association constituted in accordance with the 1901 French law regarding non-profitable organizations - 10, rue Henner PARIS Cedex 09 France. 1 CARE & HEALTH. APPLICATION FORM

5 CARE & HEALTH YOUR HEALTH DECLARATION FORM Please complete this health declaration for yourself and any dependant (spouse or child) that you have named in your Application Form KINDLY COMPLETE YOUR HEALTH DECLARATION Main Insured Spouse Child 1 Child 2 Child 3 1 Last name 2 First name 3 Date of birth (DD/MMM/YYYY) 4 Height Cm Inches 5 Weight Kg Ibs 6 Gender M F M F M F M F M F 7 Have you smoked over the past seven years? If yes, kindly indicate the average number of cigarettes smoked per day and when you ceased smoking if relevant 8 Over the past 10 years, have you undergone: a. A surgery? b. A laser treatment, chemotherapy, radiation therapy? 9 Over the past 5 years, have you been afflicted by an illness or or involved in an accident that resulted in: a. Sick leave for over 3 consecutive weeks? b. Having to undergo medical treatment for over a month? 10 Have you suffered from or ever been diagnosed for: a. Nervous disorders (chronic fatigue, anxiety, depression, migraine, epilepsy) b. Spinal cord disorders (lower back pain, sciatica, herniated disc, stiff neck) c. Arthritis and / or rheumatism (e.g. hip, knee, shoulder, hands) d. Heart disease and / or vascular disorders (e.g. hypertension, angina / chest pain, heart attack, heart rhythm abnormalities, aneurysm) e. f. g. Diseases of the esophagus, stomach, intestines, liver, pancreas (e.g., stomach ulcers, Crohn's disease, ulcerative colitis) Urinary problems (ex : renal colic, testicular or prostate disorders, bladder or kidney problems, polyp) A trauma, disease or illness requiring regular medical care and / or regular medical treatment 1

6 11 Have you ever performed a serological screening test as follows: If yes, kindly specify the result in the table below a. Hepatitis B virus(hbv)? b. Hepatitis C (HCV)? c. HIV (AIDS)? 12 Have you ever had addiction problems related to alcohol and / or drugs? 13 Within the next 6 months following the effective date of your contract, do you think you may : a. Go to see a doctor or require any medical test (e.g. laboratory, imaging, endoscopy) and / or see a specialist and / or seek medical or surgical treatment? b. Receive hospital treatment? (e.g. removal of tonsils, removal of a cyst, removal of a mole) CARE & HEALTH YOUR LIFE INSURANCE DECLARATION FORM Please complete this health declaration for yourself if you suscribe to the Life Insurance coverage. Main Insured 14 Do you suffer from a handicap, disability or chronic illness? 15 In the 12 months preceding the effective date of your contract, have you taken sick leave more than 3 times? 16 Do you or anyone in your family have a history of the following diseases? Heart disease, vascular, neurological, psychiatric, cancer, diabetes? 17 Are you currently on sick leave? 18 Have you been declared disabled? Are you in the process of being declared disabled? 19 Are you currently insured for health or Life insurance? Have you ever been refused, restricted or received a premium loading for a previous insurance policy? 20 Do you fly in a private or aviation club aircraft as a passenger or pilot (excluding regular commercial aircrafts)? 21 Have you suffered any medical condition other than those mentioned above? 22 Please add any other information regarding your health status that we should know. 2

7 CARE & HEALTH HEALTH DECLARATION If you answered "yes" to any of the above questions, kindly clarify the details in the table below. Question number Date of declaration of the first symptoms Date of the last symptoms Treatments, tests and results Complementary precisions Main insured Spouse Child 1 Child 2 Child 3 3

8 Care & Health - QM - Offshore - GMCG ANG - 04/2013 DECLARATION AND AUTHORISATION 1. To ensure medical confidentiality, you must submit this questionnaire and any medical documents sealed and marked confidential, addressed to the attention of the medical board of HENNER GMC: Medical board (Care & Health Application) health.declaration@henner.com 2. Please provide your answer on a separate piece of paper and attached it to this Declaration when sending if you need more space to provide your response. If you are applying with more than 3 children, please complete a second form for the additional children. 3. I certify that the statements above are complete, accurate and truthful and agree to provide the medical board of HENNER - GMC all the medical information that they need. Any misrepresentation or omission shall render the policy null and void and the premiums paid will be retained by the insurer as damages. The Insured and his dependants will have to refund the benefits they have received. Your (compulsory):... (This is necessary for our medical board to contact you in regards to this health declaration). Signed in (City, Country): Date (dd/mm/yy):... Signature(s) of the Insured and all dependants who have reached majority with the mention "read and approved": HENNER - Simplified private joint stock company - Registered capital of 8,212,500 - RCS Paris B TVA intra communautaire FR ORIAS (available at - Regulated by the ACP (Prudential Supervisory Authority) - ISO 9001 certified by Bureau Veritas Certification - Certificate Headquarters: 10 rue Henner Paris Cedex 09 - France Hauteville Insurance Company Limited - Harbour House - Les Amballes - St Peter Port Guernsey GY1 4QA - Channel Islands - Licenced by the Guernsey Financial Services Commission - Register number: La Garantie Médicale et Chirurgicale - Association constituted in accordance with the 1901 French law regarding non-profitable organizations - 10, rue Henner PARIS Cedex 09 France 4