Application form Bupa By You Ex Group Scheme Transfer Thank you for choosing Bupa This form should be completed by you, the intermediary on behalf of your client. Please complete this application form as fully as possible. Before you begin Please complete this form using BLOCK CAPITALS and BLACK INK Remember to give us as much detail as you can about your client and any family members that they wish to have covered. Your client must ensure that they answer all the questions honestly and to the best of their knowledge. If they don t their policy may be cancelled, or treated as if it never existed, or claims may be rejected or not fully paid. Upload the completed form onto the intermediary quote tool or if you are unable to do so, please contact the Consumer Intermediary team on 0800 33 2000*, option 2 Once we have received and processed your client s application they will receive a welcome pack in the post. *We may record or monitor our calls. For office use only Date application received Name of applicant D D M M Y Y Y Y
1. Bupa By You Please tick the relevant boxes to indicate which options your client requires. Please note that the choice of scheme and excess level may impact on the premium your client pays for the cover. Core cover Comprehensive 500 Comprehensive 750 Comprehensive 1,000 Comprehensive Cover options NHS cancer cover plus (This cover option is not available for any transferring member in the process of any cancer claims) Full cancer cover Hospital network choice Essential Extended Extended plus central London Add ons Dental cover level 10 (NHS) Dental cover level 20 (Private) Health expenses cover 10 Health expenses cover 20 Travel Europe Travel Worldwide Cancer assist Complementary therapies Main applicant/ member Member 2 Member 3 Member 4 Member 5 Excess options (please tick) 0 100 150 200 250 500 1,000 2,000 Intermediary details Bupa agency number Intermediary name Telephone number Email address 2
2. Main applicant details To see how we use your client s information, please read our privacy notice on page 9. Mr Mrs Miss Ms Other (please list title if other) Surname First name(s) Address Postcode Telephone number Mobile number Email address Date of birth D D M M Y Y Y Y Sex at birth Male Female Occupation (please note: we will request proof of applicant occupation) If your client is already a member of Bupa, please give us their membership/registration number below. If your client would like any members of their family (partner, children etc) to be included in their membership, please go to section 3. If not, go to section 4. 3. Your client s family s details If your client would like to cover members of their family, please give us their details below. Remember to check with each family member that you have their correct details. Please note that the inclusion of each family member will impact on the premium you pay for the cover. Full name of family member Relationship to you Member 2 Member 3 Member 4 Member 5 Date of birth D D M M Y Y D D M M Y Y D D M M Y Y D D M M Y Y Sex at birth Male Female Male Female Male Female Male Female What if your client needs to add more family members? If your client would like to cover family members additional to those listed above, please give us their details on a separate sheet of paper. Your client will also need to answer both parts of section 4 for them. 3
4a. Further details Please answer each question as it applies for your client and each person named in section 3. (If your client is an existing member and is only adding family members, please use the underwritten application/amendment form.) Full name of family member Main member Member 2 Member 3 Member 4 Member 5 (Please tick the relevant box) Yes No Yes No Yes No Yes No Yes No Have you been a UK resident for more than six months? Are you registered with a GP in the UK? Have you been registered with your GP for at least six months? If you are not registered with a GP currently or have not been for at least six months, do you have access to your full medical records in English? (Please note that to continue with your application you must be registered with a UK GP and if under six months, have access to your full medical records in English) If you have answered No to any questions above please provide details Do you play a sport on a professional or semi-professional basis? If Yes, which sport(s)? Please call us for available cover Have you smoked any tobacco products in the last two years? (over 18s only) Additional questions If you tick yes to any of the below questions please provide further details overleaf 1. In the last 5 years have any of the applicants being covered had any form of cancer that s not already excluded on their existing scheme? 2. In the last 5 years have any of the applicants had a heart or circulatory condition that s not already excluded on their existing scheme (for example coronary artery disease, angina and heart attacks, stroke, abnormal heart rhythms, blood clots or aneurysms, heart valve disorders, uncontrolled high cholesterol/blood pressure etc)? 3. In the last 2 years have any of the applicants had any arthritic conditions and/or back, neck and spinal conditions (including sciatica) or joint replacements that are not already excluded on their existing scheme? 4. Do any of the applicants have any planned or pending investigations, treatment or surgery for any condition or symptom that s not already excluded on their existing scheme (this applies whether the treatment is planned privately or under the NHS)? 4
4b. Further details To help us build a more complete picture of your client s (and their family s) health, please use the space below to expand on any of the conditions that were answered Yes to in part 4a. Please be specific, and give as much detail as possible. Main applicant Question 1: Question 2: Question 3: Question 4: Name of member: Question 1: Question 2: Question 3: Question 4: 5
4b. Further details To help us build a more complete picture of your client s (and their family s) health, please use the space below to expand on any of the conditions that were answered Yes to in part 4a. Please be specific, and give as much detail as possible. Name of member: Question 1: Question 2: Question 3: Question 4: Name of member: Question 1: Question 2: Question 3: Question 4: 6
5. Paying for the client s cover Subscription quoted Payment is made by monthly direct debit. Please ensure your client completes the Direct Debit instruction on page 10. When would your client(s) like their cover to start? Day Month Year Please note: Although we will try to start your client s cover on the date indicated above, this cannot be guaranteed. Your client s start date will be confirmed on their membership certificate. Please note we will not backdate start dates to a date prior to receipt of the application. 6. Obtaining medical reports from a GP Important: Please read this declaration carefully before signing and dating the completed form. Your client consents to Bupa obtaining a written medical report from their/family member s consultant or general practitioner in order to support their application or claim, made using this form. Your client/client s family members understand that they have rights under the Access to Medical Reports Act 1988 or the Access to Personal Files and Medical Reports (NI) Order 1991 (the Acts ). The Your rights section below summarises your client/their family members rights under the Acts. Your client and their family members should read this section carefully and if they don t understand any point, they should ask for further information. Your client/client s family members s rights 1. They can authorise the disclosure of the doctor s report without asking to see it. The report will then be sent directly to us by the doctor. Should they give their consent to the disclosure of a report without indicating their wish to see it, your client can change their mind by contacting their doctor before the report is sent to us, in which case they will have the opportunity to see the report and ask the doctor to change the report or add their comments before it is sent to us, or withhold their consent for its release. 2. They can give their consent but ask to see the report before it is sent to us. If your client does this they should contact their doctor within 21 days of sending the request to him/her. If they do not contact the doctor within the 21 day period they have authorised them to disclose the report to us directly without further notice to your client. If they do contact their doctor within the 21 day period they must give them their written consent to disclose the report. Your client may ask their doctor to change the report if they think it is misleading. If their doctor refuses, they can insist on adding their own comments to the report before it is sent to us. 3. They can withhold their consent but, if they do, please bear in mind that we may be unable to process your client s request. Whether or not your client indicates that they wish to see the report before it is sent, they have the right to ask their doctor to let them see a copy, provided your client asks him/her within six months of the report having been supplied to us. Your client s doctor is entitled to withhold some or all of the information contained in the report if, in their opinion, this information (a) might cause serious harm to their physical or mental health or that of another person, or (b) it would reveal the identity of another person without their consent (other than that provided by a healthcare professional in their professional capacity in relation to their care). Your client s doctor may charge a fee for providing a medical report, which may be reclaimable from Bupa. Your client/client s family members do (NOT*) wish to see the medical report from their consultant or general practitioner before it is supplied to Bupa. *Delete the word NOT if you wish to see the medical report. 7
7. Your legal declaration By submitting this form I the intermediary understand that I am bound by the terms of this legal declaration. Important: Please read this declaration carefully before signing and dating the completed form. I confirm the following: 1. The client has declared that to the best of their knowledge and belief the information given in this form is true, accurate and complete. The client understands that Bupa can end a person s policy or refuse to pay a claim in full or part if there is reasonable evidence that they or a dependant did not take reasonable carewhen providing any information requested in this form. 2. Where the client has provided information on behalf of any other person to be covered by the policy, I have checked with the client that the information about each other person is also correct before completing this form and the client has confirmed that they have express agreement from each individual to submit this form on their behalf. 3. The client has declared they understand their personal information and that of any other person to be covered by this policy will be processed by Bupa for the purposes set out in Bupa s privacy notice. The client has provided me with confirmation that they have brought Bupa s privacy notice to the attention of any other person who will be covered by the policy. 4. The client has declared they agree to be bound by the terms of this policy (including in respect of those terms that apply to any other person to be covered by this policy). The client has confirmed they understand and agree that English law will apply to the policy. It is essential that the client takes reasonable care to provide full, complete and accurate information when you complete this form. Please be sure to check the entire form. If the client does not provide complete information about themselves or any other person covered under the policy, we will have the right to end their policy, or to refuse to pay all or part of a claim. We recommend that you and the client keep a record of all the information you supply to us in connection with this form, including letters. If you or the client would like a copy of this form, please ask us. This form must be received by us within six weeks of the date of this declaration. Fill in the form with complete up-to-date medical history before you sign and date it. If we do not receive this application form within six weeks of this declaration date, we will require you to submit a new form. Obtaining medical reports from your GP: The client/client s family members have confirmed that they understand that Bupa may need them to provide a medical report from their GP within the first 24 months of their membership before treatment is authorised The client/client s family members have agreed to Bupa obtaining this information from their GP on their behalf and they understand that Bupa will gain verbal confirmation from them prior to any medical report being requested in this way The client has confirmed that they understand the rights they have in relation to such reports as explained in section 6 The client has confirmed that they have shown this declaration to the proposed dependants on the policy and confirm that they understand that if they need to claim they will be asked on the telephone to confirm their consent to Bupa requesting a medical report on their behalf If the client does not wish Bupa to request medical reports on their behalf in this way, please tick this box Signature Date D D M M Y Y Y Y 8
Bupa privacy notice in brief We are committed to protecting your privacy when dealing with your personal information. This privacy notice provides an overview of the information we collect about you, how we use and protect it. It also provides information about your rights. Further details can be found in our Full Privacy Notice available at bupa.co.uk/privacy. If you do not have access to the internet and would like a paper copy of the Full Privacy Notice, please contact the Bupa Privacy team on +44 (0) 1784 893706. Alternatively you can email the team at dataprotection@bupa.com or write to Bupa Data Protection, Willow House, 4 Pine Trees, Chertsey Lane, Staines-Upon-Thames, Middlesex TW18 3DZ. If you have any questions about how we handle your information, please contact us at dataprotection@bupa.com Information about Bupa In this privacy notice, references to we or us or our are to Bupa. Bupa is registered with the Information Commissioner s Office, registration number Z6831692. Bupa is comprised of a number of trading companies, many of which also have their own data protection registrations. For company contact details, visit bupa.co.uk/legal-notices Scope of our privacy notice This privacy notice applies to anyone who interacts with us in relation to our products and services ( you, your ), via any channel (eg email, website, telephone, app etc). Ways in which we obtain personal information We obtain personal information from you and from certain third parties (eg those acting on your behalf, like brokers, healthcare providers etc). Where you provide us with information about other individuals, you must ensure that they have seen a copy of this privacy notice and are comfortable with you doing this. Categories of personal information We process two categories of personal information about you and/or, where applicable, your dependants, namely standard personal information (eg information we use to contact you, identify you or manage our relationship with you); and special categories of information (eg health information, information about race, ethnic origin and religion that allows us to tailor your care, and information about crime in connection with screening). Purposes and lawful grounds of our processing personal information We process your personal information for the purposes set out in our Full Privacy Notice, including to administer our relationship with you (including for claims and complaints handling), for research and analysis, to monitor our expectations of performance (including of health providers relevant to you) and in order to protect the rights, property, or safety of Bupa, our customers, or others. The legal ground upon which we process personal information depends on what category of personal information we process. Standard personal information is normally processed by us on the basis that it is necessary for the performance of a contract, our or a third parties legitimate interests or it is required or permitted by applicable law. Marketing and preferences We may use your personal information to send you marketing by post, telephone, social media platforms, email and text. We only use your personal information to send you marketing if we have either your consent or a legitimate interest. If you don t want to receive personalised marketing about similar Bupa products and services that we think are relevant to you, please contact us at optmeout@bupa.com or write to Bupa Data Protection, Willow House, 4 Pine Trees, Chertsey Lane, Staines-Upon- Thames, Middlesex TW18 3DZ Processing for Profiling and Automated Decision Making Like many businesses, we sometimes use automation to provide you with a quicker, better, more consistent and fair service, as well as with marketing information we think will be of interest (including discounts on our products and services). This may involve evaluating information about you and, in some limited cases, using technology to provide you with automatic responses or decisions. You can read more about this in our Full Privacy Notice. You have the right to object to direct marketing and profiling relating to direct marketing. You may also have rights to object to other types of profiling and automated decision-making. Further details are available in our Full Privacy Notice. Sharing your information We share your information within the Bupa Group, with relevant policyholders (including your employer if you are covered under a group scheme), with funders commissioning services on your behalf, those acting on your behalf (eg brokers and other intermediaries) and with others who help us provide services to you (eg healthcare providers) or from whom we need information to handle or verify claims or entitlements (eg professional associations). We also share your information in accordance with the law. You can read more about what information may be shared in what circumstances in our Full Privacy Notice. Transfers outside of the European Economic Area (EEA) Bupa deals with many international organisations and uses global information systems. As a result, Bupa transfers your personal information to countries outside of the European Economic Area ( EEA ), (the EU member states plus Norway, Liechtenstein and Iceland) for the purposes set out in this privacy policy. How long we retain your personal information Bupa retains your personal information in accordance with retention periods calculated in accordance with the criteria detailed in the Full Privacy Notice available on our website. Your rights You have rights to have access to your information and to ask us to rectify, erase and restrict use of your information. You also have rights to object to your information being used, to ask for the transfer of information you have made available to us, to withdraw consent to the use of your information and not to be subject to automated decision-making which produce legal effects concerning you or similarly significantly affects you. Data Protection Contacts If you have any questions, comments, complaints or suggestions in relation to this notice, or any other concerns about the way in which we process information about you, please contact us at dataprotection@bupa.com You also have a right to make a complaint to your local privacy supervisory authority. Bupa s main establishment is in the UK, where the local supervisory authority is the Information Commissioner, who can be contacted at: Information Commissioner s Office, Wycliffe House, Water Lane, Wilmslow, Cheshire SK9 5AF, United Kingdom. Tel: 0303 123 1113 (local rate) or 01625 545 745 (national rate). 9
Direct Debit instruction Instruction to your Bank or Building Society to pay by Direct Debit Please complete the white areas in BLOCK CAPITALS and BLACK INK to instruct your bank to make payments directly from your account. Then return the completed form to: Bupa Insurance Services Limited, Anchorage Quay, Salford Quays M50 3XL Originator Identification Number 9 9 1 3 6 4 1. Name and full postal address of your Bank or Building Society branch To: The Manager Bank or Building Society Address 5. Bupa reference/membership number For Bupa Insurance Services Limited official use only This is not part of the instruction to your Bank or Building Society Note to member: Please complete your member/group name below (if applicable) Postcode 2. Name(s) of account holder(s) 3. Branch sort code 4. Bank or Building Society account number 6. Instruction to your Bank or Building Society Please pay Bupa Insurance Services Limited Direct Debits from the account detailed in this instruction subject to the safeguards assured by the Direct Debit Guarantee. I understand that this instruction may remain with Bupa Insurance Services Limited and, if so, details will be passed electronically to my Bank/Building Society. Signature(s) Date D D M M Y Y Y Y Banks and Building Societies may not accept Direct Debit instructions for some types of account. This guarantee should be detached and retained by the Payer. The Direct Debit Guarantee This Guarantee is offered by all banks and building societies that accept instructions to pay Direct Debits. If there are any changes to the amount, date or frequency of your Direct Debit Bupa Insurance Services Limited will notify you 10 working days in advance of your account being debited or as otherwise agreed. If you request Bupa Insurance Services Limited to collect a payment, confirmation of the amount and date will be given to you at the time of the request. If an error is made in the payment of your Direct Debit by Bupa Insurance Services Limited or your bank or building society you are entitled to a full and immediate refund of the amount paid from your bank or building society. If you receive a refund you are not entitled to, you must pay it back when Bupa Insurance Services Limited asks you to. You can cancel a Direct Debit at any time by simply contacting your bank or building society. Written confirmation may be required. Please also notify us. Should you wish to cancel this instruction through Bupa Insurance Services Limited, please call us on 0345 609 0111. You must allow a minimum of seven days before the next payment by Direct Debit is due. We may record or monitor our calls. 10
Final checklist Before you return the form have you: DD Ticked the cover option in Section 1 DD Included full details of all the family members your client would like to cover DD Checked with your client s family members that their details are correct DD Remembered to sign and date the form. DD Made sure you and your client have a copy of this form for your own records Upload completed form onto the intermediary quote tool or if you are unable to do so please contact the Consumer Intermediary team on 0800 33 2000*, option 2 Once we have received and processed the application your client will receive a welcome pack in the post. *We may record or monitor our calls. 11
Bupa health insurance is provided by: Bupa Insurance Limited. Registered in England and Wales No. 3956433. Bupa Insurance Limited is authorised by the Prudential Regulation Authority and regulated by the Financial Conduct Authority and the Prudential Regulation Authority. Arranged and administered by: Bupa Insurance Services Limited, which is authorised and regulated by the Financial Conduct Authority. Registered in England and Wales No. 3829851. Registered office: 1 Angel Court, London EC2R 7HJ. Bupa 2018 bupa.co.uk BBY/2985/MAY18 BHF 10212