Antrag für eine Internationale Krankenversicherung

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Ethelbert Tate
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Antrag für eine Internationale Krankenversicherung Bitte senden Sie Ihren ausgefüllten und unterschriebenen Antrag sowie die Erklärung (letzte Seite) entweder per Fax

1 Antrag für eine Internationale Krankenversicherung Bitte senden Sie Ihren ausgefüllten und unterschriebenen Antrag sowie die Erklärung (letzte Seite) entweder per Fax an: oder per an: oder per Post an: OSD International GmbH & Co. KG Im Martelacker 8 D Efringen-Kirchen Germany

2 Evolution Health Plan Moratorium Application form Please complete this form and return it to your agent/insurance broker. It is important that you complete this form fully. Failure to do so may result in the form being returned to you for completion. All proposals are reviewed prior to acceptance and therefore no cover shall be granted until confirmation is provided. 1 Your personal details Title Forename(s) Surname Date of birth Gender Height Weight Overseas address Post/Zip code Phone Mob Home address Post/Zip code Occupation Country of residence Nationality Home country (for which you have a passport) How long have you been resident in your country of residence (years/months)? 2 Cover required Date upon which annual cover to commence, or the date on which your proposal is accepted by insurers, whichever is the later Choose your area of cover Europe Worldwide excluding USA, China, Singapore & Hong Kong Worldwide excluding USA Worldwide Choose your level of cover Standard Standard Plus Comprehensive Premium Elite Please select the annual excess you wish to apply to your policy Nil Please specify the currency in which you wish to pay premiums and receive benefits US Dollar $ Sterling Euro Page 1 of 4 Evolution Health Plan Moratorium Application form ARM/MORIAPP/01/18

3 2 Cover required continued Do you or any of the persons to be included in this proposal, have existing health insurance? Yes No If yes, which provider? Have you or any of the people to be included in the proposal, ever been refused cover by an insurance company or been accepted on special terms? (If yes provide details on a separate sheet) Yes No 3 Additional modules Home country evacuation module (120 adult/75 child) 4 Dependants to be included Full name of dependants Relationship to proposer D.O.B Nationality Gender Height Weight Occupation Page 2 of 4 Evolution Health Plan Moratorium Application form ARM/MORIAPP/01/18

4 5 Moratorium This policy has a two year moratorium. This means that pre-existing conditions will not be covered during the first two years of the policy. After this a pre-existing condition may be covered if a period of two consecutive years has elapsed since any symptoms, treatment, medication, tests or advice was received for that condition. 6 Data Protection Act 1998 Morgan Price International Healthcare Ltd is registered under the data protection act We will collect information in the course of your dealings with us regarding your personal details (including but not limited to your sex, age, ethnic origin and state of health). Any information we do collect will only be used for the purpose of conducting our relationship with you and will be used for the purposes of underwriting your insurance cover, managing the policy we issue for you, and administering any claims you may make. We may need to transfer some or all of this information to our insurance underwriters, their claims handlers, medical assistance companies or other medical practitioners. You have the right to access any details that we hold about you and to amend or delete anything that you may believe is inaccurate or out of date. By signing this declaration you are consenting to us using the information we hold about you in the ways described above. Without this consent we are unable to offer you any insurance cover. Declaration a. I/We have read the policy wording and I/We understand it to be part of the contract of insurance. In particular I/We have read, understand, and accept the definitions, benefits and exclusions of the policy. b. I/We have read, understand and accept sections 4 and 5 of this proposal. c. To the best of my/our knowledge and belief the information given in connection with this proposal, whether in my hand or not, is true and I/we have answered all questions about this policy honestly and fully. I/We also understand that I/we must tell the insurer straight away if anything that I/we have already told the insurer changes. I/We understand that nondisclosure or misrepresentation of any facts may entitle the insurer to void the insurance. This proposal and the information provided contains statements upon which the insurers will rely in deciding whether to accept this insurance and in determining the terms and conditions of such acceptance. d. I/We understand that the signing of this proposal does not bind me/us to complete, or insurers to accept this insurance. e. If I/We have elected to pay our premium by instalments using credit or debit cards and Morgan Price have agreed to this, I/we authorise Morgan Price to continue to deduct such instalments as and when they become due unless I/we cancel this credit card authorisation by giving at least 14 days notice in writing. I/we understand that if I/we have made a claim, no refund will be due and I/we will have to pay any outstanding instalments due in the current period of cover. Signature of primary applicant Date Page 3 of 4 Evolution Health Plan Moratorium Application form ARM/MORIAPP/01/18

5 6 Payment method Please specify how you would like to pay Annually by credit/debit card Semi annual by credit/debit card Quarterly by credit/debit card Monthly by credit/debit card Annually by bank transfer - details supplied on request Monthly by direct debit - only available in the EU on Euro policies only Additional surcharges - credit/debit card & SEPA Direct Debits Annual payment Semi annual payments Quarterly payments Monthly payments 0% +4% +5% +8% For Amex payments add an additional 3.5% to the surcharges above (for USD payments only). American Express cards can only be used for USD payments and incur a further 3.5% charge: i. If paying by credit/debit card please complete attached payment form Additional surcharges - bank transfer Annual bank transfer 10/ 15/$30 The bank transfer fee does not need to be included as long as the payee selects to pay all charges. Page 4 of 4 Evolution Health Plan Moratorium Application form ARM/MORIAPP/01/18

6 2 Credit/debit card details Please only complete if you are paying by credit/debit card. I authorise you, until further notice in writing, to charge my credit/debit card account unspecified amounts in respect of premiums for my Evolution Health Plan subscription, as and when these become due, until this instruction is countermanded by my giving notice in writing. I understand I will be given at least one months notice of any subscription increase. i. If you have chosen to pay by instalment, the credit/debit card details provided must be in date for the entirety of the policy. Name on card Card type Visa Mastercard American Express (for USD policies only) Other If other, please specify Card number CVC Issue no Start date Expiry date Payment frequency Card billing address - if different from residential address Signature of card holder Post/Zip code Date ii. You must keep your credit/debit card details confidential and secure. For security reasons please do not credit/debit card details to us. If you do so, it is entirely at your own risk. Agent stamp Page 2 of 2 Evolution Health Plan Premium payment form MPIH/PYT/01/18

7 SEPA CORE DIRECT DEBIT MANDATE MORGAN PRICE INTERNATIONAL HEALTHCARE LTD 11A FORGE BUSINESS CENTRE UPPER ROSE LANE PALGRAVE DISS, NORFOLK. IP22 1AP UNITED KINGDOM Creditor ID : GB30ZZZSDDBARC By signing this mandate form, you authorise Morgan Price International Healthcare Ltd to send instructions to your bank to debit your account and for your bank to debit your account in accordance with the instructions from Morgan Price International Healthcare Ltd. As part of your rights, you are entitled to a refund from your bank under the terms and conditions of your agreement with your bank. A refund must be claimed within 8 weeks starting from the date on which your account was debited. Your rights regarding this mandate are explained in a statement that you can obtain from your bank. If you utilise your rights above, the insurance that you use this mandate to purchase will be suspended until payment is received and the terms and conditions of the policy will be applied. All fields are mandatory. Mandate Reference In respect of the contract Type of Payment Recurrent (Mandate can be used more than once) Your Details Your address: One-off (Mandate can only be used once) Country: Your bank BIC Postcode: Your account number (IBAN) Date of signature City/town in which you are signing Signature:

8 Declaration the insurance broker: OSD International GmbH & Co. KG, Im Martelacker 8, Efringen-Kirchen, Germany -hereafter called broker - and Ms Mr Company Name: Adress: hereafter called Client - conclude the following agreement: The client contacted the broker by own will, he was not acquired neither by the broker nor by third parties and exclusively ordered an offer for international health insurance. Consultation was done only via telephone or . The client decided to take out insurance of the provider Morgan Price. The client expressly foregoes the following services of the broker: 1. the detailed risk evaluation and the creation of a customer profle according to a need analysis and the associated need determination 2. the full scope of market monitoring and market exploration based on the limited consultation desired and accepted by the customer 3. the full scope of protocolling the consulting The client confrms that he received suffcient consultation concerning the products mediated by the broker. He was provided with the premium and tariff tables, lists of services and the insurance conditions of the selected tariff (and if applicable further alternative tariffs of other providers) prior to application. The client read these documents and understood them. He had suffcient time to review the offers and rethink his decision in every way. The broker is not able to consider possibly existing local conditions concerning possible insurance obligations in his consultation. This is the client's responsibility alone. The client hereby relieves the broker from any liability in the sense of the mediating and consulting performance. The client was provided with the business card of the broker prior to application (if applicable in electronic form). The client read and understood the below stated declaration. The client accepts the brokers data protection guidelines which can be found on The client accepts that the broker will use and store the clients personal data to process the application and ongoingly serve the client as such. The client accepts that the broker will forward the clients personal information and all relevant documents to the insurer which the client selected, by Post, electronically and/or over the phone. The client accepts that the broker may contact him without further request by Post, electronically and/or over the phone as part of his ongoing consultation services regarding the selected insurance plan. Place Date Clients Signatue DELCARATION: OSD International GmbH & Co. KG hereby declares that OSD has no direct or indirect participation of over 10% to the capital or the voting rights of a certain insurance company. In addition, no insurance company holds shares of the OSD International GmbH & Co. KG in the above described manner. The OSD International GmbH & Co. KG also confirms that OSD is not contractually obligated to undertake insurance mediation services with one or several insurance companies. OSD International GmbH & Co. KG possesses the legally prescribed limited liability insurance with the legally set insurance sums Location: Efringen-Kirchen - Manager: Steffen Dantz - registered at the District Court Freiburg i.br.: HRA Revenue Office Lörrach, Sales tax.-id: DE Mutual office in the sense of & 11 a GewO: DIHK e.v. - Breite Straße Berlin - Registration pursuant to & 1 1a GewO: D-LNF2- AAZ9E Responsible: IHK Hochrhein-Bodensee, Schützenstr. 8, Konstanz - Arbitration board: Versicherungsombudsmann e.v. - PF D Berlin - Supervisory authorities: BAFin - Graurheindorfer Str D Bonn - General partner: OSD Internional Verwaltungs- GmbH - Im Martealcker Efringen-Kirchen - Registered at the District Court Freiburg i.br.: - HRB Manager Steffen Dantz

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