PROPOSAL FOR HOSPITAL / MEDICAL INSURANCE

Transcription

1 PROPOSAL FOR HOSPITAL / MEDICAL INSURANCE Important Note: Under Section 25(5) of the Insurance Act Cap 142 or any subsequent amendment thereof, you are to disclose in this proposal form, fully and faithfully all the facts which you know or ought to know, otherwise the policy issued hereunder may be void. SECTION A : PARTICULARS OF PROPOSER Name (as shown in NRIC / Passport)- Please underline surname Dr Mr Mrs Miss Date of Birth (dd/mm/yyyy) NRIC / Passport No. Gender Female Male Marital Status Single Married Widowed Divorced Separated Age Next Birthday Nationality Singapore PR? Yes No Residential Address Correspondence Address (if different from address above) Address Contact No. (Home) (Office) (Mobile) Occupation Name & Address of Employer Nature of Work Height (m) Weight (kg) Do you currently live or intend to live in another country for more than 3 months during the coming year? If Yes, please give details. SECTION B: PARTICULARS OF FAMILY MEMBERS TO BE INSURED Relationship Full Name ( as in NRIC / Passport ) NRIC / Passport No Nationality Gender ( M/F ) Proposer Date of Birth ( dd/mm/yyyy ) Occupation Height ( m ) Weight ( kg ) Dependant 1 Spouse Child Dependant 2 Child Dependant 3 Child Indiv Page 1 of 10

2 SECTION C: DECLARATION ON RESIDENCY STATUS Please answer on behalf of all family members to be insured Proposer Dependant 1 Dependant 2 Dependant 3 A. FOR SINGAPORE CITIZENS ONLY i. As a citizen of Singapore, have you resided outside Singapore continuously for 5 or more years preceding the proposal date of the policy? ii. As a citizen of Singapore, are you currently residing in Singapore? B. FOR SINGAPORE PRS ONLY i. As a Singapore PR, have you resided in Singapore for less than a total of 183 days in the 12 months preceding the proposal date of the policy? C. FOR NON SINGAPORE CITIZENS AND NON SINGAPORE PRS ONLY i. Do you have a work pass or permit required under the Employment of Foreign Manpower Act (Cap. 91A) ii. If you answer yes to C(i), have you resided in Singapore for less than a total of 183 days in the 12 months preceding the proposal date of the policy? iii. Do you have a pass or permit required under Immigration Act (Cap. 133) that has duration longer than 90days? iv. If you answer yes to C(iii), have you resided in Singapore continuously for at least 90 days during the 12 months preceding the proposal date of the policy? This policy shall be deemed as an Singapore Policy if the individual, (i) Is a citizen of Singapore, unless he has resided outside Singapore continuously for 5 or more years preceding the proposal date of the policy and is not currently residing in Singapore; (ii) Is a permanent resident, unless he has resided in Singapore for less than a total of 183 days in the 12 months preceding the proposal date of the policy; (iii) Has a work pass or permit required under the Employment of Foreign Manpower Act (Cap. 91A), unless he has resided in Singapore for less than a total of 183 days in the 12 months preceding the proposal date of the policy; or (iv) Has a pass or permit required under the Immigration Act (Cap. 133) that has a duration longer than 90 days and has resided in Singapore continuously for at least 90 days in the 12 months preceding the proposal date of the policy. Indiv Page 2 of 10

3 SECTION D: HEALTH DECLARATION i ) HABITS OF INSURED PERSON(S) Please answer on behalf of all family members to be insured Proposer Dependant 1 Dependant 2 Dependant 3 1. Have you ever smoked in the last 12 months? If Yes, please provide details of smoking. a. No. of sticks you smoke per day b. No. of years since you have been smoking 2. Do you consume beer, wine or other alcoholic beverages? If Yes, please provide details of alcohol consumption: a. Type of alcohol taken: b. Average weekly consumption with units of measurement 3. Do you engage in or intend to engage in any sport(s) or occupation of a dangerous / hazardous nature? E.g. scuba/skin diving, motor racing, military / private flying other than as a fare paying passenger, parachuting, etc? If Yes, please state details on the type of sports you participate in: ii ) PARTICULARS OF HEALTH OF INSURED PERSON(S) Please answer on behalf of all family members to be insured Proposer Dependant 1 Dependant 2 Dependant 3 1. Has any proposal for life or disability or health assurance on your life to this or any other insurance office ever been declined, postponed or accepted at other than normal terms? 2. Are you now receiving or considering to receive medical treatment from a doctor or intending to consult any doctor for any reason? 3. Have you ever undergone any health screening or had any medical investigations carried out, whether on your on accord or on the recommendation of a doctor, such as X-ray, ultrasound, electrocardiogram (ECG), barium meal examination, CT scan, biopsy, blood or urine test, etc., in the past 5 years? 4. Have you ever taken drugs, narcotics, glue sniffing or been treated for drug addiction? 5. Have you ever had or been treated for alcoholism? 6. Have you ever had or been told to have or been treated for :. a. Diabetes, thyroid disorders, or any other endocrine disorders? b. Asthma, persistent cough, coughing with blood, pneumonia, tuberculosis, bronchitis, chest or breathing complaints or discomfort, and/or any other lung disorders? c. Raised cholesterol, high blood pressure, heart attack, rheumatic fever, Kawasaki disease, heart murmur, palpitation, coronary artery disease, mitral valve prolapse, or other heart valve disorders, breathlessness, irregular or fast heart rate, chest discomfort or chest pain, and/or any disease or disorders of the heart of blood vessels? d. Epilepsy, fits, stroke, paralysis, dementia, Parkinson s disease, multiple sclerosis, motor neurone disease, weakness of limbs, polio, fainting spells, prolonged headache, unconsciousness, nervous breakdown, depression, or any other nervous or mental disorders, or disease of the brain? Indiv Page 3 of 10

4 ii ) PARTICULARS OF HEALTH OF INSURED PERSON(S) (continued) Please answer on behalf of all family members to be insured Proposer Dependant 1 Dependant 2 Dependant 3 e. Gastritis, stomach or duodenal ulcer, blood in the stools, fistula, hernia, haemorrhoids or piles, irritable bowel syndrome, or any other stomach or bowel disorders? f. Jaundice, hepatitis B carrier or any form of hepatitis, liver disorder or gall bladder disorder? g. Albumin or protein in urine, blood or sugar in urine, kidney stones, infection or any other disorders of the kidney, bladder, urinary or genital organs? h. Slipped disc, gout, any form of arthritis, joint pain or deformity, and/or disorders of the muscles, spine, limbs or joints or severe injury? i. Anaemia, any other disorders of the blood, advised to abstain from donating blood, or received blood transfusion or blood products on account of haemophilia or any other reason? j. Ear discharge, nose bleeds, double vision, or visual impairment or impaired hearing or speech, or any other disorders of the ear, nose throat? k. Cancer, tumours, cysts or growths of any kind? l. Congenital anomalies, physical disability or any unusual skin lesions, or any other illness, disorder, operation, hospital admission, accident or injury not mentioned above? 7. Have you or your spouse been told to have, or received any medical advice or counselling or treatment in connection with sexually transmitted disease, AIDS, or AIDS Related Complex or any other AIDS related condition? 8. a. Have you ever had HIV testing done? b. Have you ever in the last 3 months had any of the following symptoms for more than one week continuously: fatigue, weight loss, diarrhoea, enlarged nodes or unusual skin lesions? Do you have a regular attending doctor? 9. If Yes, please state the name of doctor and the address of the clinic 10. FOR FEMALE ONLY (Also to be completed for child(ren) aged 12 years and above) a. Have you ever been found to have or are you aware of any breast lumps or any other disease or disorders of the breast? b. Have you ever suffered from irregular or painful or unusually heavy menstruation, fibroids, cysts or any disorders of the female organ? c. Have you ever had any abnormal pap smear within the six months? d. Have you been advised to have mammogram, biopsy, operation of the breasts, ultrasound of the pelvis or any other gynaecological investigations? Indiv Page 4 of 10

5 ii ) PARTICULARS OF HEALTH OF INSURED PERSON(S) (continued) Please answer on behalf of all family members to be insured Proposer Dependant 1 Dependant 2 Dependant 3 e. Are you pregnant now? Yes No Yes No Yes No Yes No If Yes, please state the weeks / months of pregnancy. wk / mth wk / mth wk / mth wk / mth f. Were there any complications during any of your pregnancy such as gestational diabetes, hypertension, etc? If the answer to any questions in Section D is Yes, please provide with FULL DETAILS here. Question No. Name of Person Concerned (Employee/ Spouse/ Child(ren)) Details of Diagnostic Test with reason & result / Doctor s Diagnosis / Injury / Treatment Duration of Illness From To Name of Doctor Consulted & Address of Clinic iii ) FAMILY HISTORY OF INSURED PERSON(S) Has any of your parents or siblings died or suffered from cancer (specify type), heart disease, stroke, high blood pressure, diabetes, kidney disease, mental disorder, tuberculosis or any hereditary disease(s)? (If Yes, please provide details below) If Alive Relationship (Father, Mother, Sister or Brother) Please indicate type of Medical Condition and the exact Diagnosis If Deceased Age at time of Diagnosis Age at Death Cause of Death Indiv Page 5 of 10

6 SECTION E: DECLARATION / REPLACEMENT OF EXISTING MEDICAL INSURANCE Are you or any of your family members currently insured under or applying for any medical insurance? If Yes, please provide details: Name of Insured Name of Company Type of Policy Annual Limit Expiry Date Is the insurance now applied for intended to replace any of the policy(ies) listed above? If Yes, which policy (ies) and state the reasons for replacement. NOTE : It is usually not advantageous to replace an existing medical insurance with a new one for the following reasons : (a) the insurance may not be granted on the same terms; (b) the benefits may or may not be better compared to the existing plan; (c) a higher premium may have to be paid for the new plan. SECTION F : DETAILS OF COVER ( Please select one plan type only ) Asean Plus Optima Plus Optima Health a. Plan I Plan II b. 5% Family Discount a. Plan I Plan II Plan IV Plan VI b. Premium Reduction Option Option A Option B c. 5% Family Discount a. Plan I Plan II Plan IV Plan VI b. Premium Reduction Option Option A Option B c. 5% Family Discount SECTION G: DETAILS OF PAYMENT Payment Frequency Annual payment) Initial Payment Method Monthly (for monthly payment, multiply by and provide 3 months upfront Cash (please do not send cash via mail) Cheque : Bank Cheque No (Crossed and made payable to ) Total Premium Due (Inclusive of GST) SGD Subsequent Payment Method Interbank GIRO (to complete interbank GIRO form) Credit Card (please complete credit card details in Section H) Credit Card (please complete credit card details in Section H) Payor s Details (if the Payor is NOT the Proposer or Proposed Life Insured): Name of Payor: _ *NRIC/ Passport Number: Relationship to Proposer/ Owner: Source of Wealth/ Funds: Reason for making payment for Proposer/ Proposed Life Insured: *Please enclose copy of Payor s NRIC/ Passport Indiv Page 6 of 10

7 SECTION H: CREDIT CARD PAYMENT INSTRUCTIONS I hereby authorise to charge the following premium(s), Including extra premium (if any), to my credit card account for this insurance application. This authorisation shall remain in effect until I terminate it by written notification to at least 30 days in advance of the intended date of termination. Name of Cardholder (as in NRIC or Passport) NRIC or Passport Number Relationship to Proposer VISA MasterCard Credit Card Number Credit Card Expiry Date Signature of Card Holder Date Indiv Page 7 of 10

8 SECTION I: PERSONAL DATA PROTECTION NOTIFICATION I/ We acknowledge that: 1) To process, administer and/or manage My/Our relationship, account and policy with Raffles Health Insurance Pte. Ltd., You will necessarily need to collect, use, disclose and/or process My/Our personal data or personal information about Me/Us. Such personal data includes: (i) information set out in this proposal/ application form and any other personal information provided by Me/Us or possessed by Raffles Health Insurance Pte. Ltd. and (ii) my/our claims. 2) Such personal data will be collected, used, disclosed and/or processed by Raffles Health Insurance Pte. Ltd. for the purpose(s) of : (a) considering whether to provide Me/Us with the insurance I/We applied for; (b) processing My/Our application for underwriting and insurance; (c) Administering and/or managing My/Our relationship, account and/or policy with Raffles Health Insurance Pte. Ltd.; (d) processing and/or dealing with any claims including the settlement of claims and any necessary investigations relating to the claims, under My/Our policy; (e) Carrying out due diligence or other screening activities (including background checks) in accordance with legal or regulatory obligations or risk management procedures that may be required by law or that may have been put in place by Raffles Health Insurance Pte. Ltd.; (f) Carrying out My/Our instructions or responding to any enquiries by Me/Us; (g) Dealing in any matters relating to the services and/or products which I/We are entitled to under this policy which I/We are applying for or have applied; (including the mailing of correspondence, statements, invoices, reports or notices to Me/Us, which could involve disclosure of certain personal data about Me/Us to bring about delivery of the same as well as on the external cover of envelopes/mail packages); (h) Investigating fraud, misconduct, any unlawful action or omission, whether relating to My/Our application, My/Our claims or any other matter relating to My/Our policy, and whether or not there is any suspicion of the aforementioned; and/or (i) Complying with applicable law in administering and managing My/Our relationship with Raffles Health Insurance Pte. Ltd. (j) sending me marketing, advertising and promotional information about other insurance, investment and/or financial products and/or services that Raffles Health Insurance Pte. Ltd. may be selling or marketing, and which Raffles Health Insurance Pte. Ltd. believes may be of interest or benefit to me, by the following modes of communication : postal mail, electronic transmission to my address, SMS/MMS (text message) and fax; Please tick this box if you do not wish to receive communication via postal mail, , SMS/MMS (text message) and fax. to my telephone number(s): ; ; by way of : (Collectively the Purposes ) voice call (Please tick this box if you do not wish to receive communication via voice calls) 3) Raffles Health Insurance Pte. Ltd. may/will also be collecting from sources other than Myself/Ourselves, personal data about Me/Us, for one or more of the above Purposes, and thereafter using, disclosing and/or processing such personal data for one or more of the above Purposes. 4) My/Our personal data may/will be disclosed by Raffles Health Insurance Pte. Ltd. to its reinsurers, third party service providers or agents (including its lawyers / law firms), which may be sited outside of Singapore, for one or more of the above Purposes, as such third party service providers or agents, if engaged by Raffles Health Insurance Pte. Ltd, would be processing My/Our personal data for Raffles Health Insurance Pte. Ltd. for one or more of the above Purposes. 5) By signing on this proposal or application form, I/We consent to Raffles Health Insurance Pte. Ltd in: (a) collecting, using, disclosing and/or processing My/Our personal data for the Purposes as described above; (b) collecting personal data about Me/Us from sources other than Myself/Ourselves and using, disclosing and/or processing the same, for one or more of the Purposes as described above; (c) disclosing My/Our personal data to its third party service providers, or agents (including its lawyers / law firms), for the Purposes as described above; and (d) transferring My/Our personal data out of Singapore to its third party service providers, or agents where such third party service providers or agents are sited (whether in Singapore or outside of Singapore), for the Purposes as described above. (e) representing and warrant that My/Our personal data provided in this form, for the purpose as described above and have read and understood the above provisions. Important Note: Individuals aged 16 and above are required to provide consent for the collection, use, and disclosure of their personal information. Indiv Page 8 of 10

9 SECTION J: DECLARATION AND AUTHORISATION I/We hereby declare and confirm that (a) The answers given in this proposal are complete and true, and whether written by me/us or by anyone else on my/our behalf, I/We hereby accept full responsibility for them; and agree that they shall form part of my/our proposal, which shall be the basis of the contract of insurance. (b) I/We have not withheld any material information in completing this proposal. I/We understand that benefits will not apply to treatment or expense arising from medical conditions which originated or were known to exist or for which treatment, medication, advice or diagnosis was sought or received prior to my/our enrolment in the Policy unless such conditions are fully disclosed to and accepted by prior to the inception of the Policy. I/We understand that my/our application will be subject to acceptance by, and that I /We will not be insured under any of the insurance plan(s) for which I/We are subject to acceptance until advises I/Us the terms and conditions on accepting insurance on I/Us, and that reserves the right to decline insurance or impose special terms and conditions. I/We were duly informed that any payment made at the time of this proposal or thereafter shall be construed as a deposit (free of interest) and be held by you until an unequivocal acceptance of this proposal from you. I/We understand that : (a) If my/our application for insurance under any of the above plan(s) is accepted, my/our Insurance under the plan shall terminate if the Policyholder does not renew the plan upon expiry of any period of Insurance, or cancel the plan(s), or if I/We attain the age at which the Insurance terminates as specified in the terms and conditions of the Insurance plan(s), and (b) These plans(s) are yearly renewable and that the terms and conditions of the Insurance plan(s) I/We are insured under, including the premium payable, at any renewal of the plan(s), may change upon agreement between the Policyholder and. I/We agree that should I/We decide to cancel the Policy issued in respect of this proposal within 14 days after receipt of the Policy document, the amount refunded to me shall be the premium paid less any expenses paid in underwriting the Policy. However, should the proposal be declined then I/We shall be entitled to a full refund of the premium paid. I/We agree that the policy is issued as a Singapore policy (unless declared otherwise under section C) expressed in Singapore dollars and all payments under the policy, whether to or by you will be payable in Singapore dollars in Singapore. I/We also agree that the policy will be entered in the register of Singapore policies (unless declared otherwise under section C). I/We hereby authorize any hospital, medical practitioner, clinic or other medical related facility, insurance company or other organizations or persons to release to you any information concerning my/our medical condition or history. I/We confirm that I/We have been given a copy of the booklet Your Guide to Health Insurance and read through the Product Summary, the contents of which have been explained to me to my/our satisfaction. [Not applicable for Direct Marketing] WARNING : If a material fact is not disclosed in this proposal, any policy issued may not be valid. If you are in doubt as to whether a fact is material, you are advised to disclose it. This includes any information that you may have provided to the insurance advisor/agent but was not included in the proposal. Please check to ensure that you are fully satisfied with the information declared in this proposal. Signed in Singapore on: (day) (month) (year) Signature of Proposer : Signature of Dependent 1 (Spouse): Signature of Dependent 2: Signature of Dependent 3: Signature of Witness/ Insurance Advisor: Name & NRIC : Note: Dependents aged 16 and above are required to sign. Indiv Page 9 of 10

10 SECTION K: INSURANCE ADVISOR S DECLARATION 1. I declare that all the answers provided to me by the Proposer or Proposed Life Insured(s) are declared in the Proposal/ Application Form. I have not withheld any other information which may influence the underwriting or acceptance of this Proposal by the Company. 2. I have explained the terms of the insurance to him/ her and have verified the NRIC/ Passport/ Birth Certificate/ ACRA business profile of the Proposer/ Owner/ Proposed Life Insured(s). Insurance Advisor s Signature: Name & NRIC: Date: Policy Number Period of Insurance For Office Use From To Proposal Received Name of Advisor Advisor s Code Premium Received Referral Source Commission / Referral Fee Indiv Page 10 of 10