Globe Partner Association - Individual Membership ...In case of a complaint, please write to ACS Complaint Service attal our pos address. ACS is controlled by the ACPR, 4 place de

I the undersigned ____________________ Usual / married name ______________________________ First name(s) ______________________________

DOB in _________________________________________________________ Nationality ________________________________

Sex: ☐ F ☐ M

Marital status: ☐ single ☐ married ☐ widow ☐ divorced ☐ marital life ☐ civil unionAddress in France: ______________________________________________________________________________________________________________

_____________________________________________________________________________________________________________________________

Address in country of origin: _______________________________________________________________________________________________________

_____________________________________________________________________________________________________________________________

Phone: ______________________________ E-mail: ____________________________________________

Passport n°: ________________________________

• request membership of the individual « health » coverage schemes☐ for myself alone, ☐ for myself and my family of which the beneficiaries are as follows :

Kinship Sex (M or F)

Family name First names DOB (dd/mm/yyyy)

Spouse1st child2nd child3rd child4th child

☐ F ☐ M☐ F ☐ M☐ F ☐ M☐ F ☐ M☐ F ☐ M

_________________________________________________________________________________________________________________________________________________________________________________________

____________________________________________________________________________________________________________________________________________________________________________________

Health cover (only one choice possible) Annual contribution 1

___________________ €Coverage level :

- Expatriate insurance plan ☐ * ☐ ** ☐ ***- Health cover 1st € - Coverage area France and European Economic Area excluding the United Kingdom

• request membership of the Assistance and Civil Liability coverage

Assistance and Civil Liability Annual contribution 2

Coverage area Worldwide except USA, Canada, Switzerland, Israel, Japan, Hong Kong and SingaporeAssistance cover ☐ yes ☐ no ___________________ €Civil liability ☐ yes ☐ no ___________________ €

Globe Partner Association - Individual Membership Application - ACS France

Beyond the 4th child please submit the information on a separate sheet of paper. For children over 20 years old, a school attendance certificate must be provided.

☐ ****

A C S – I N SURANC E B ROK E RAGE COMPANY 1 5 3 RU E D E L ’ UN I V E R S I T E 7 5 0 0 7 P A R I S – F r a n c e T E L + 3 3 ( 0 ) 1 4 0 4 7 9 1 0 0 Email : contact@acs‐ami.com Web site : www.acs‐ami.com

317 218 188 RCS Paris –S.A.S (Simplified joint‐stock company) with a share capital of 150 000 € N° ORIAS 07 000 350 (www.orias.fr) In case of a complaint, please write to ACS Complaint Service at our postal address. ACS is controlled by the ACPR, 4 place de Budapest, CS 92459, 75436 Paris Cedex 09 France

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• request membership of the individual Contingency coverage

Contingency (only one choice possible) Annual contribution 3

Gross annual income in Euro (if contingency coverage) __________________________€

1 - Death option ☐ Essential (25 000 €) ☐ Comfort (50 000 €) ☐ Excellence (100 000 €) __________________ €(complementary to health cover - cannot exceed two times the stated gross annual income)

Beneficiary designation in the event of death☐ 1st formula : I choose the type designation below :In the event of death, the lump sum shall be paid to : the no separated spouse of married policy holder, the civil union partner or cohabitant, or failing, to the children born or to be born of the policy holder, In equal shares between them, the predeceased share being allotted to his own children or brothers and sisters if he or she has no children, failing, the father and mother in equal fractions, the precedeceased’s share being paid to the survivor, or failing, the heirs.

☐ Essential (Benefits 25€/day) ☐ Comfort (Benefits 50€/day) ☐ Excellence (Benefits 100 €/day) __________________ €(complemetary to death option - cannot exceed 70 % of the stated gross annual income)

Scheme 1st €

Grace period ☐ 90 days ☐ 180 days

The amount of my first annual contribution for Health (1) + Assistance (2) + Contingency (3) is _________________ € Annual contribution 4

I want my membership to become effective on

Contributions are payable in advance. Annual Globe Partner Association membership costs: 20 € per contract.

Payment method : ☐ debit of credit card ☐ bank transfer ☐ cheque ☐ standing orderFrequency : ☐ calendar year ☐ calendar half-year ☐ calendar quarter year ☐ month

payable to ACS, corresponding to the premium pro rated to time between the effective date and the first Instalment : I settle the amount of EUR ___________calendar insurance period + EUR 20 membership fees by :

☐ debit of credit card ☐ bank transfer ☐ cheque ☐ standing order

In ___________________________________ on

References of broker

_________________________

☐ 2nd formula : I do not opt for the 1st formula and designate as my beneficiary ______________________________________________________________ ______________________________________________________________________________________________________________________________

By choosing this formula, the Insured shall provide several successive beneficiaries and if he wants an exact distribution between each beneficiary, indicate the share for each of them by ending with «failing, my heirs». If no option is chosen, the first 1st formula is applied.

2 - Disability option

Globe Partner Association - Individual Membership Application - ACS France

Read and approved

______________________Signature



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Individual membership application - About your personal information

The information collected by ACS, insurance broker, simplified joint-stock company registered under number 317 218 188 RCS Paris, and located at 153, rue de l’Université – 75007 Paris, France, either directly from you or via your insurance intermediary, is subject to data processing for the sole purpose of:

• preparing, concluding, managing and executing your quote or contract (study of needs, underwriting, calculation and collect of premium, preparation of endorsements, claims management, treatment of complaints if any…),

• enforcing regulations related to anti-money laundering and terrorist financing prevention, fight against fraud,• elaborating statistical and actuarial studies,• redistributing risks via reinsurance or coinsurance.

They will be retained 3, 5 or 10 years in accordance with applicable laws and regulations.

The processing of such data is carried out in compliance with the requirements applying to the collection, processing, recording, organization, purpose limitation and data minimization, storage, adaptation or alteration, retrieval, consultation, use, disclosure by transfer, dissemination, security of personal data.

The recipients of such data are, within the limits of their relevant assignments and according to applicable purposes, the insurers, reinsurers, insurance intermediaries (your direct broker, if applicable), and eventually their subcontractors, which intervene in the context of the execution or the management of your contract, third party administrators, the mediator if a case is submitted to him/her, authorities legally authorized to manage your complaints, Tracfin for the fight against terrorism and anti-money laundering. Your data may also be transmitted to any person benefiting from the contract (subscriber, insured, member, and beneficiary of the contract).

You expressly accept the collection and processing of data concerning your health. This information is necessary for the execution and the management of your contract and your benefits, which is the sole purpose of the processing, and made in accordance with the regulations of medical confidentiality. This information is exclusively intended for the medical advisors of ACS, its departments in charge of managing your benefits, its third-party administrators and assistance providers if applicable, as well as for the insurers and reinsurers of your contract.

In addition, we inform you that your personal data, or that of other parties concerned by or benefiting from the contract, may be transferred outside the European Union if necessary for the performance of your contract.

The sole purpose of such transfers is to allow the performance of insurance and assistance claims, and only the data necessary for the achievement of this purpose are transferred.

The recipients or categories of recipients authorized to receive the data are the accredited staff of the medical administrators and assistance companies as well as of the insurers, where appropriate.

These transfers are made according to the regulations relating to the protection of personal data applicable in the European Union.

In accordance with the French data protection law n° 78-17 of January 6 1978 as amended in 2004 and 2018 and to EU regulation 2016/679 of April 27th 2016, you have the right to Access, Rectify, Erase, and to the Portability of, any data concerning yourself, as well as the rights to the Restriction of and to Object to the processing of your personal data, which you can pursue by writing to our Data Protection Officer: [email protected] or by postal mail to « ACS, To the attention of the DPO, 153, rue de l’Université, 75007 Paris, France » (together with a copy of an official ID).

You may send a complaint:

• On the CNIL website by filling out the online form.• By postal mail writing to CNIL - 3 Place de Fontenoy - TSA 80715 - 75334 PARIS CEDEX 07 FRANCE

Regarding your health data, these rights may also be exercised by writing to the ACS Medical Consultant (ACS, To the attention of the Medical Consultant, 153, rue de l’Université, 75007 Paris, France) together with of a copy of an official ID.

You may receive commercial offers from our company for products or services similar to those you have requested. Should you wish to receive commercial offers from our company, please check this box:



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A C S – I N S U R A N C E B R O K E R A G E C O M P A N Y 1 5 3 R U E D E L ’ U N I V E R S I T E 7 5 0 0 7 P A R I S – F r a n c e T E L + 3 3 ( 0 ) 1 4 0 4 7 9 1 0 0 Email : [email protected] Web site : www.acs-ami.com

317 218 188 RCS Paris –S.A.S (Simplified joint-stock company) with a share capital of 150 000 € N° ORIAS 07 000 350 (www.orias.fr) In case of a complaint, please write to ACS Complaint Service at our postal address. ACS is controlled by the ACPR, 4 place de Budapest, CS 92459, 75436 Paris Cedex 09 France

Medical questionnaire

INSTRUCTIONS: An answer is expected for each question. Any extra information regarding the state of your health may be added in the « Complementary information » section you will find after the questionnaire.

Insured Last name : ___________________________________ First name : ____________________________________ Date of birth : ____/____/________ Occupation : ______________________________ Email : _____________________________________ Height : _________ m Weight : _________ kg

Spouse Last name : ___________________________________ First name : ____________________________________ Date of birth : ____/____/________ Occupation : ______________________________ Email : _____________________________________ Height : _________ m Weight : _________ kg

Children 1- First name : ____________________ Height : ______ m Weight : ______ kg 3- First name : ____________________ Height : ______ m Weight : ______ kg2- First name : ____________________ Height : ______ m Weight : ______ kg 4- First name : ____________________ Height : ______ m Weight : ______ kg

Tobacco consumption Alcohol consumptionInsured Spouse Insured Spouse

Do you smoke? Do you drink alcohol? Cigarettes/day Beer (glasses/day) Cigars/day Wine (glasses/day) Pipes/day Spirits (drinks/day)

Have you ever smoked? If yes, for how many years? (insured and spouse) When did you stop and why? (insured and spouse)

Insured Spouse Child 1 Child 2 Child 3 Child 4 Note : if you need more space for your answers, please use the "complementary information" section you will find below. 1- Do you have or have you ever had a congenital or hereditary disorder?

If YES, please indicate which disorder, onset date & treatment:

2- Does your present state of health prevent you from performing your full time occupation?

Therapeutic Part Time leave: Total leave of absence: Reasons:

3- Have you undergone or been advised to undergo surgery, other than for the extraction of the appendix, tonsils or adenoids?

Details of surgery? Dates(s) ?

4- During the last 5 years, have you had / do you have any medical treatment (medication, acupuncture, physiotherapy, medical appliances, psychotherapy…), excluding birth control ? Are you currently undergoing diagnostic tests ?

Details :

5- During the past 5 years, have you been prescribed sick leave or a medical treatment exceeding 3 weeks?

Please give reasons?

6- Have you received care or undergone tests during the past 5 years which have led to stay in a medical establishment (hospital, clinic, convalescent home, physiotherapy, dietary needs or treatment centre, sanatorium…)?

Date(s) ? (Please attach photocopies of post-operative and cell reports)

7- During the last 24 months, have you had any symptoms for which you did not consult a health professional and which should have been treated ?

Details:

8- Over the next 6 months, is it planned for you to have any medical examinations (laboratory tests, medical imaging, endoscopy…) consult a specialist or undergo medical and/or surgical treatment on an inpatient or outpatient basis ?

Details:

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Insured Spouse Child 1 Child 2 Child 3 Child 4 Note : if you need more space for your answers, please use the "complementary information" section you will find below. 9- During the past ten years have youexperienced any of the following?

a) High blood pressure /hypertension, diabetes, cholesterol problem, stroke, lung, heart or circulatory disease b)Respiratory or allergic condition, emphysema, bronchitis, pneumonia, sleep apnea, asthma c) Anxiety, headaches, drug or alcohol abuse, neurological or psychological illness (including depression)d) Gastritis, gastro-esophageal reflux, stomach or intestinal ulcers, hernias, urinary tract or liver disorders (hepatitis, gallstones and kidney stones, renal failure, lithiasis…), prostate, thrombosise) Sciatica, herniated discs, lumbar pain, rheumatism (including the vertebrae) arthritis, any skin condition such as keratosis, melanoma...f) Any hormonal or glandular disease, blood or immune system disease, cancer, leukemia or other blood related illness g) For women only : have you in the past ten years had any gynecological disorder ?h) Have you had any other medical problemsnot mentioned on the questionnaire ?

If you answered YES to this question, please indicate which illness and state clearly all relevant details (date, duration, treatment, recovery date, after effects, comments). Please attach photocopies of medical reports.

10- Do you plan to get hospitalized in the upcoming 12 months?

If YES, indicate the nature of the hospitalization:

11- Have you had a screening for the AIDS, hepatitis virus or for one of the human Immuno-deficiency viruses?

If YES, please indicate the date, nature of the test and result:

12- Have you had any after-effects resulting from an accident or illness?

Details :

13- Do you suffer from a disability or are you entitled to a disablement pension (civilian or military) or old age pension?

Nature of disability: Rate (please attach notification):

14- Are you currently covered by any medical or Life policy ? Has any medical or Life insurance application been declined, rated, restricted, or cancelled?

Complementary information

You can use the section below if, in the previous section, you couldn't complete all the details regarding a medical condition. Please do not forget to note the question number and the person concerned. This will help us process your application promptly.

Question # _____ Person: ___________________________ Question # _____ Person: ___________________________

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I hereby declare that the above statements are full, complete and true to the best of my knowledge and belief, and that I have not declared or omitted to declare any particular that may mislead the insurer. It is fully agreed that the penalties which apply in the case of false statement, concealment or inaccuracy, are the nullity of the contract or the reduction of the level of coverage.

I agree that in the case of false or incomplete statement, the insurer has the right to reduce the level of, or refuse, coverage.

Signed in (town or city) _____________________ Date (DD/MM/YYYY) __________________

Read and approved

____________________

Signature of the insured members aged 18 years old or more

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Standing order authorization

CREDIT CARD DEBIT AUTHORIZATION

I the undersigned, Mr, Mrs, Miss, ___________________________________ , holder of the below mentioned credit card, authorize the establishment where is located my bank account to proceed, if this situation permits, with the debits requested for by the hereafter mentioned company. In case of dispute, I can ask the establishment where is located my bank account to suspend any debits on my card and I will settle the dispute directly with the creditor company.

Name, first name and address of the card holder Creditor company

Name and first name _______________________________________________Address _________________________________________________________________________________________________________________________ZIP code City ________________________________________Country _________________________________________________________

ACSSociété de Courtages d’Assurances

153, rue de l’Université75007 Paris - France

Account to be debited

Type of credit card : ☐ Visa ☐ Mastercard ☐ Eurocard ☐ AMEX Number of the card to be debited Expiration date (month/year) / Security code (3 digits on the back of the card)

Frequency of debit : ☐ annual ☐ half-yearly ☐ quarterly ☐ monthly

Date ________________________Signature of the card holder

Please fill out the form that corresponds to the payment method of your choice.

For payments via standing order (valid only for holders of bank accounts located in France), please completethe standing order mandate you will find in the next page.

http://www.acs-ami.com/en

SEPA DIRECT DEBIT MANDATE

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Creditor's name and logo

By signing this mandate form, you authorise the creditor to send instructions to your bank to debit your account, and you authorise your bank to debit your account in accordance with the instructions from the creditor. 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 (eight) weeks following the date on which your account was debited

Unique Mandate Reference (UMR)

Debtor identification codeWrite any code number here which you wish to have quoted by your bank

Party on whose behalf thepayment is made (if not the debtor)

In respect of the contract

Identification code of third-party debtor

Contract identification number Description of contract

Identification code of third-party creditor

Name of the third-party debtor: if your payment relates to an arrangement between the creditor and a third party (for example if you are paying a bill on behalf of another person), please writethe other person's name here. If you are paying on your behalf leave blank.

Please complete the fields marked *

Your name * .....................................................................................................................................................................................................Debtor's family name and given names

Your address * .....................................................................................................................................................................................................Number and road name

* ................................... .................................................................................................... .........................................................Post code Town/City Country

Your bank account *details International Bank Account Number - IBAN

*Bank Identifier Code for your bank - BIC

Creditor's name * .....................................................................................................................................................................................................Creditor's name

SCI *SEPA Creditor Identifier (SCI)

* .....................................................................................................................................................................................................Number and road name

* ................................... .................................................................................................... .........................................................Post code Town/City Country

Type of payment * q Recurrent payment q Punctual payment

Signed at * .......................................................................................................................................... Place Date (DD/MM/YYYY)

Signature(s) * Please sign here

Note: Your rights regarding the above mandate are explained in a statement that you can obtain from your bank.

Details regarding the contract between the creditor and the debtor -

For creditor's use only Please return to:

Maximum name lenght 70 characters

This line is a maximum of 35 characters long

Name of third-party creditor: the creditor must complete this section if collecting payment on behalf of another party

The information contained in this transfer order, which must be completed, must only be used by the creditor for the purpose of managing therelationship with the customer. Customers may exercise their right to access, rectify or refuse the processing of this information provided forunder articles 38 and following of the French data protection law, no. 78.17, dated 6 January 1978.

Assurances Courtages et Services

Ville_2: Pays_2: Name_1: POB_1: Nationality_1: case_1: Offcase_2: Offcase_3: Offcase_4: Offcase_5: Offcase_6: Offcase_7: Offcase_8: Offadresse_1: adresse_2: adresse_3: adresse_4: tel_1: passeport_1: case_moi_seule: Offcase_moi_famille: Offcase_11: Offcase_13: Offcase_15: Offcase_17: Offcase_19: Offcase_12: Offcase_14: Offcase_16: Offcase_18: Offcase_20: OffName_5: DOB DDMMYYYY_2: Name_6: DOB DDMMYYYY_3: Name_7: DOB DDMMYYYY_4: Name_8: DOB DDMMYYYY_5: cotisation annuelle 1: case_21: Offcase_24: OffCotisation annuelle assistance: case_37: Offcase_38: Offcase_39: Offcase_40: OffCotisation annuelle responsabilite: income_1: case_41: Offcase_42: Offcase_43: OffCotisation annuelle 3: case_44: Offcase_45: Offformula_1: formula_2: case_145: Offcase_146: Offcase_147: OffCotisation invalidité: case_148: Offcase_149: OfftotalCotisation: 0date adhésion: case_245: Offcase_247: Offcase_248: Offcase_246: Offcase_345: Offcase_344: Offcase_346: Offcase_347: Offacompte: case_444: Offcase_445: Offcase_446: Offcase_447: OffA_100: DOB DDMMYYYY_1000: Références de lIntermédiaire: Je soussignée M Mme Mle: Nom et Prénom: Adresse 1: Adresse 2: codePostal: Ville: Pays: typeCarte: Offcb1: cb2: cb3: cb4: moisCb: anneeCb: nsecu: periodPrev: OffUnique Mandate Reference (UMR): Debtor's family name and given names: Number and road name_1: Post code_1: City_1: Country_1: International Bank Account Number - IBAN: Bank Identifier Code for your bank – BIC: Creditor's name: ASSURANCES COURTAGES ET SERVICESSEPA Creditor identifier (SCI): FR 44 ZZZ 494888 Number and road name_2: 153 RUE DE L'UNIVERSITEPost code_2: 75007City_2: PARISCountry_2: FRANCECase 1: OuiCase 2: OffSigned at: Debtor identification code: Third party debtor: Identification code of third party debtor: Name of third party creditor: Identification code of third party creditor: In respect of the contract: EXPATRIATE CONTRACTContract identification number: Please return to: ASSURANCES COURTAGES ET SERVICES153 RUE DE L'UNIVERSITE 75007 PARIScase_28: Offcase_281: Offoffres-comm: OffDate: le: Profession_Assuré: Taille_Assuré: Poids_Assuré: Profession_Conjoint: Email_Conjoint: Taille_Conjoint: Poids_Conjoint: Enfant1_Taille: Enfant1_Poids_3: Enfant2_Taille: Enfant2_Poids: Enfant3_Taille: Enfant3_Poids: Enfant4_Taille: Enfant4_Poids: Fumez_vous_assuré: Offcigarettes_assuré: [ ]cigares_assuré: [ ]pipes_assuré: [ ]cigarettes_conjoint: [ ]cigares_conjoint: [ ]pipes_conjoint: [ ]Fumez_vous_conjoint: Offbière_assuré: [ ]vin_assuré: [ ]spirit_assuré: [ ]bière_conjoint: [ ]vin_conjoint: [ ]spirit_conjoint: [ ]alcool_assuré: Offalcool_conjoint: OffSi oui combien de temps avezvous fumé assuré principal et conjoint: Depuis quand avezvous arrêté de fumer et pourquoi assuré principal et conjoint: ExFumeur_Assuré: OffExFumeur_Conjoint: OffQM1_A: OffQM1_C: OffQM1_E1: OffQM1_E2: OffQM1_E3: OffQM1_info_1: QM1_E4: OffQM2_A: OffQM2_C: OffQM2_E1: OffQM2_E2: OffQM2_E3: OffQM2_E4: OffQM2_info_1: QM2_info_2: QM2_info_3: QM3_info_1: QM3_E4: OffQM3_E3: OffQM3_E2: OffQM3_E1: OffQM3_C: OffQM3_A: OffQM4_A: OffQM4_C: OffQM4_E1: OffQM4_E2: OffQM4_E3: OffQM4_info_1: QM4_E4: OffQM5_A: OffQM5_C: OffQM5_E1: OffQM5_E2: OffQM5_E3: OffQM5_info_1: QM5_E4: OffQM6_A: OffQM6_C: OffQM6_E1: OffQM6_E2: OffQM6_E3: OffQM6_info_1: QM6_E4: OffQM7_A: OffQM7_C: OffQM7_E1: OffQM7_E2: OffQM7_E3: OffQM7_info_1: QM7_E4: OffQM8_A: OffQM8_C: OffQM8_E1: OffQM8_E2: OffQM8_E3: OffQM8_E4: OffQM8_info_1: QM9_info_1: QM9_A: OffQM9_C: OffQM9_E1: OffQM9_E2: OffQM9_E3: OffQM9_E4: OffQM10_info_1: QM10_A: OffQM10_C: OffQM10_E1: OffQM10_E2: OffQM10_E3: OffQM10_E4: OffQM11_info_1: QM11_A: OffQM11_C: OffQM11_E1: OffQM11_E2: OffQM11_E3: OffQM11_E4: OffQM12_info_1: QM12_A: OffQM12_C: OffQM12_E1: OffQM12_E2: OffQM12_E3: OffQM12_E4: OffQM13_info_2: QM13_info_1: QM13_A: OffQM13_C: OffQM13_E1: OffQM13_E2: OffQM13_E3: OffQM13_E4: OffQM14_info_1: QM14_A: OffQM14_C: OffQM14_E1: OffQM14_E2: OffQM14_E3: OffQM14_E4: OffInfos_Sup_Question_1: Infos_Sup_Personne_1: Infos_Sup_Contenu_1: Infos_Sup_Question_2: Infos_Sup_Personne_2: Infos_Sup_Contenu_2: Infos_Sup_Question_3: Infos_Sup_Personne_3: Infos_Sup_Contenu_3: Infos_Sup_Question_4: Infos_Sup_Personne_4: Infos_Sup_Contenu_4: Infos_Sup_Question_5: Infos_Sup_Personne_5: Infos_Sup_Contenu_5: Infos_Sup_Question_6: Infos_Sup_Personne_6: Infos_Sup_Contenu_6: Infos_Sup_Question_7: Infos_Sup_Personne_7: Infos_Sup_Contenu_7: Infos_Sup_Question_8: Infos_Sup_Personne_8: Infos_Sup_Contenu_8: Infos_Sup_Question_9: Infos_Sup_Personne_9: Infos_Sup_Contenu_9: Infos_Sup_Question_10: Infos_Sup_Personne_10: Infos_Sup_Contenu_10: QM_Fait_à: Date_QM: Nom_Assuré: Prénom_Assuré: Date de naissance_Assuré: Email_Assuré: Nom_Conjoint: Prénom_Conjoint: Date de naissance_Conjoint: Enfant1_Prénom: Enfant2_Prénom: Enfant3_Prénom: Enfant4_Prénom:

Documents

Globe Partner Association - Individual Membership ...In case of a complaint, please write to ACS Complaint Service attal our pos address. ACS is controlled by the ACPR, 4 place de