Pacific Prime - Bupa Lifeline Application Form
one of the most comprehensive international health insurance coverage companies in the world, BUPA offers many services and options that other insurers cannot. Bupa Lifeline is one of their International Health Insurance Products, brought to you in association with Pacific Prime Insurance Brokers. Please visit our Bupa specific page for more information: http://www.pacificprime.com/insurers/bupa/
- 1. Joining Bupa InternationalYour application - Lifeline
- 2. i m p o rta n t i n f o r m at i o n Please write clearly in black ink and BLOCK CAPITALS. Mail or fax us your completed application. Our fax number is: +44 (0) 1273 866 585. If you fax us your application, please do not mail us the original as well. Our postal address is Bupa International, Russell House, Russell Mews, Brighton, BN1 2NR. United Kingdom. If you have any questions when completing this form, please call us on +44 (0) 1273 208 181 Checklist - please make sure: you have read, signed and dated the declaration We will not be able to process your application if in section 13 this form is incomplete. the information you have given in sections 1-12 is correct and complete Please be sure to check the for payments by Direct Debit or Credit Card, you have completed the Direct Debit Instruction or the entire form. Credit Card Authority Main member: your personal details m 1 m The date you want your cover to start: D D M M Y Y Your cover cannot start before the date we receive your completed application form. Title First name Other initials Family name Male / Female Nationality 1st Language Occupation Date of birth D D M M Y Y Do you have current medical cover with any other insurer, including Bupa? Yes No If Yes, please give details: Name of other health insurer Name of scheme / cover Membership numberIf you are joining the ECIS plan and you or your employer hold current ECIS membership, please send us proof of membership with this form. Main member: your address details (please let us know straightaway about any change of address) m 2 m Residency address (your permanent or usual address in the country where you are resident. Correspondence address (where membership documents cannot easily be sent to you at This should be the country in which you are living on the first day of your current membership year.) your residency address, please supply an alternative address to which they may be sent) Building name / number Building name / number Street Street Town/City Town/City Postal / zip / area code Postal / zip / area code Region Region Country CountryIf you have been living in the UK for 90 days or more out of the last 120 days at the start of your current membership year, then you are deemed residentin the UK. Does this apply to you? Yes No Do you have a residence in the USA? Yes No Main member: your other contact details m 3 m Main contact (home) Secondary contact (work) Country code Area code Number Country code Area code Number Telephone Telephone Fax Fax Mobile Mobile Email Email
- 3. 4 Additional persons to be covered with you Title First name 1 1st additional person Other initials Family name Male / Female Nationality 1st Language Occupation Date of birth D D M M Y Y Relationship to you Title First name 2 2nd additional person Other initials Family name Male / Female Nationality 1st Language Occupation Date of birth D D M M Y Y Relationship to you Title First name 3 3rd additional person Other initials Family name Male / Female Nationality 1st Language Occupation Date of birth D D M M Y Y Relationship to you Title First name 4 4th additional person Other initials Family name Male / Female Nationality 1st Language Occupation Date of birth D D M M Y Y Relationship to you If any of these additional persons have different home or correspondence addresses to yours, please write their name and addresses on a separate sheet and confirm you have done so by ticking here: 1 i m p o rta n t i n f o r m at i o n It is important that the information you give in sections 5, 6 and 8 matches the correct persons from sections 1 and 4. . estion Y Y qu udeM them every ected No to st incl this fo susp u mu M ome uage Yes or own or rnation al d on e outc le n D etaile se tick y kn Inte t, yo as th ers d Section 6: t Lang . 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- 4. 5 Confidential medical historyThis section asks for health and medical details, past and present about yourself and each person named in Section 4. Please tick Yes or No to every questionfor every person. If you tick Yes to a question, please give full details in Section 6 on the next page. Please ensure you tell us about any known or suspectedconditions and symptoms even if professional advice has not yet been sought. If you are applying to increase cover and you are already a Bupa Internationalmember, you should also include details of any conditions for which you have made claims within the last four years.If you do not provide us with full details we may terminate your cover or it may stop us from paying your claims.Have you or anyone to be covered under the membership: zz seen a doctor or other healthcare professional in the last three years m 1 2 3 4 zz been admitted to hospital, had an operation/procedure or had an investigation (eg a scan/blood tests) in the last seven years mfor any of the medical problems listed in question 1 12 below. Please note that wehave given examples of conditions here, but not all conditions can be listed. Y N Y N Y N Y N Y N1. Heart or circulatory disorders eg high blood pressure, angina/chest pains, heartattack, heart failure, abnormal heart beat, aneurysms, or varicose veins Y N Y N Y N Y N Y N2. Endocrine (glandular) disorders eg diabetes (Type 1 or Type 2), thyroidproblems, or obesity Y N Y N Y N Y N Y N3. Breathing or respiratory disorders eg shortness of breath, asthma, COPD, chestinfections, pneumonia, bronchitis, tuberculosis or allergies (including hayfever and Y N Y N Y N Y N Y Nanaphylaxis)4. Stomach, intestines, liver or gall bladder problems eg stomach inflammation/ulcers, irritable bowel, Crohns disease, colitis, change in bowel habits, abdominal pain, Y N Y N Y N Y N Y Nhaemorrhoids/piles, pancreatitis, liver inflammation, cirrhosis, gall stones or hernias5. Cancer, tumours or growths eg polyps, benign growths, any cancers or pre-cancerous condition Y N Y N Y N Y N Y N6. Skin problems eg eczema, dermatitis, rashes, psoriasis, acne, cysts, moles thatitch or bleed, or allergic conditions Y N Y N Y N Y N Y N7. Brain or nervous system disorders eg stroke, dementia, migraine, repeatedheadaches, multiple sclerosis, epilepsy/fits, nerve pain (including sciatica and Y N Y N Y N Y N Y Nshingles) or meningitis8. Muscle or skeletal problems eg arthritis, back pain, neck/shoulder problems,cartilage and ligament problems, joint replacements, fractures, osteoporosis, gout or Y N Y N Y N Y N Y Ninflammatory conditions.9. Urinary or reproductive system problems eg kidney or bladder problems(including kidney failure), recurrent urinary infections, incontinence; pregnancy/childbirth problems (including caesarean sections), heavy or irregular periods, Y N Y N Y N Y N Y Nfibroids, endometriosis, infertility, abnormal smears, polycystic ovaries, testicular orprostate disorders.10. Blood/infective/immune disorders eg abnormal blood tests, high cholesterol,anaemia; hepatitis, HIV, malaria; or any autoimmune disorder. Y N Y N Y N Y N Y N11. Eye, ear, nose, throat and dental problems eg cataracts, glaucoma, visualimpairment; deafness, ear infections, tonsillitis; dental infections, wisdom teeth Y N Y N Y N Y N Y Nproblems or gingivitis.12. Psychiatric/ psychological disorders eg schizophrenia, compulsive or eatingdisorders; depression, stress, anxiety or drug/alcohol dependency. Y N Y N Y N Y N Y NPlease also answer the following questions:13. Is anyone to be covered taking any medication, prescribed or otherwise? Y N Y N Y N Y N Y N14. Is anyone to be covered receiving any treatment of any kind, or require orexpect to require any review, investigations or treatment for any current or past Y N Y N Y N Y N Y Nmedical problem not already mentioned in this application?15. Has anyone to be covered experienced any signs or symptoms of any medicalproblem in the last six months, regardless of whether a healthcare professional has Y N Y N Y N Y N Y Nbeen consulted?Further details (for over 16s only):How tall are you? feet/inches metres/centimetresHow much do you weigh? stones/pounds kilogrammesHave you used tobacco products within the last seven years? Y N Y N Y N Y N Y N
- 5. 6 Additional informationThis section applies if you have indicated Yes to any questions in section 5. If you are unsure whether any details are relevant, you must include them. The relevant Please specify as accurately as When did the symptoms What treatment did you receive What was the outcome question possible the name of the illness or start and when was and when (please include of the treatment number medical problem. treatment completed? dates, names and details of (eg ongoing, complete from Where applicable, please state medications)? recovery, recurrent section 5 the area of the body affected, or likely to recur)? (eg right leg, left eye). m m 1 2 3 4If there is insufficient space, please use a separate sheet and indicate that you have done so by ticking here:N.B. Please tell us immediately if you or any additional persons to be covered under the membership experience any symptoms before you receiveyour membership documents. Failure to do so may affect your claims. 7 Your doctor Doctors name Full postal addressYour consent to your doctor to disclose medical information.On behalf of myself and each person named on this form, I authorise this doctor to provide Bupa International with any information it asks for in connectionwith my membership application and any claims (past, present and future). Please tick here to give your consent:If any family members included in your application have a different doctor, please give the name and / or address details on a separate sheet - and confirmyou have done so by ticking here:
- 6. 8 Your details of cover (Note: the level of cover you choose will apply to all members detailed on this form) m 1 2 3 4 m Lifeline Essential: This level concentrates on covering you for in-patient hospital stays. You have the security that youll be covered for treatment you may receive as an in-patient or as a daycare patient. Lifeline Classic: Our Classic level is designed to cover you and your family for specialist medical treatment or diagnosis. You will be covered for in-patient hospital stays as well as out-patient consultations, treatment such as physiotherapy and a range of preventive health checks. Lifeline Gold: Our top level gives you cover for both in-patient and out-patient care. In addition, Gold also covers family doctor treatment and any prescription medication you may need, as well as accident related dental treatment. Maternity cover, home nursing and a range of four preventive health checks are also included in this comprehensive plan. USA cover: We understand that many people do not need medical insurance for the USA, so you can choose whether you want to include it. Unfortunately, we cannot offer Bupa International Lifeline to anyone who is normally resident in the USA. zzThis cover will increase your premium. Choose your Annual Deductible If you are paying by Direct Debit or Credit Card, you may choose an annual deductible. This is the amount you would pay towards eligible medical treatment each year. GBP: None 100 250 500 1000 2000 USD: None $160 $400 $800 $1600 $3200 EUR: None 160 400 800 1600 3200 9 Your assistance cover options m 1 2 3 4 m Evacuation: If you are concerned about the quality of local medical care, this is ideal. If the treatment you need is not available locally, we will arrange for you to be evacuated to the nearest centre of medical excellence, no matter where you are in the world. Repatriation (automatically includes Evacuation cover): Our highest level of Assistance cover also gives you the choice of returning to your home country, to be treated in familiar surroundings, near your friends and relatives (if treatment is not available locally). If this happens, you can choose to have someone to accompany you for your visit back home.Please refer to the membership guide for full details.
- 7. 10 Your payment details (Direct debit, credit card or cheque/bankers draft) Your choice of currency for your cover and subscription payments (please tick one only): GBP() USD($) EUR() How will you make your subscription payments (please tick one only): Monthly Quarterly Yearly By Direct Debit through a UK bank. (This is only an option for GBP() payments. Please complete the below Direct Debit Instruction): By Credit Card (please complete the below Card Payment Authority): By cheque or bankers draft in the currency you have indicated above: Who will be paying the subscription? A valid Direct Debit agreement or Card Authority is required throughout your membership year. Your cover may be suspended or terminated if you do not have such an agreement or authority in place. 11 Direct Debit (for GBP () payments only - this must come out of a UK bank account) If you are paying by Direct Debit you must complete this section. Instruction to your Bank or Building Society to pay by Direct Debit Name(s) of account holder(s): Bank/Building Society account number: Branch sort code: Instruction to your Bank or Building Society - - Please pay Bupa International Direct Debits from the account detailed in this instruction subject to the Swift code: safeguards assured by the Direct Debit Guarantee. I understand that this instruction may remain with Bupa International and, if so, details will be passed electronically to my Bank/Building Society. Name and full postal address of your Bank/Building Society: To: The Manager Address: Postcode: Cardholders signature Date Reference number (for Bupa International use only) BI - - - Originators ID number 9 8 0 9 3 9 Banks and Building Societies may not accept Direct Debit Instructions for some type of accounts. As Instruction Form 12 Credit Card authority card payment authority To Bupa International, I authorise you, until further notice in writing, to (please tick) MasterCard Visa American Express charge to my card account, subscriptions and other unspecified amounts, as and when payments become due. I will advise you immediately if the Please note that we do not accept Maestro payments. card becomes lost, stolen or if I wish to close my card account or cancel the You will be given 14 days notice of other unspecified amounts to be collected. authority. Cardholders name as it appears on the card: Card number: Valid from date: Expires/end date: - - - M M Y Y M M Y Y Cardholders signature DateThe Direct Debit Guarantee zz This Guarantee is offered by all banks and building societies that take part in the Direct Debit Scheme. The efficiency and security zz If an error is made by Bupa International or your Bank or Building Society, you are guaranteed a full and immediate refund fromThis guarantee should be detached and retained by the payer of the Scheme is monitored and protected by your own Bank or your branch of the amount paid. Building Society. zz You can cancel a Direct Debit at any time by writing to your Bank zz If the amounts to be paid or the payment dates change, Bupa or Building Society. Please also send a copy of your letter to us. International will notify you seven working days in advance of your account being debited or as otherwise agreed.
- 8. 13 Your membership declaration In view of the declaration below, it is essential that complete Bupa International Data Protection Notice information is supplied. Purpose: Personal data collected on you, and where appropriate, Benefits may not be payable if you do not fully disclose any material facts your family, will be used by Bupa International to process your claims, which could influence our assessment and acceptance of this application administer your policy and may be used to detect and prevent fraud or and, if you are in any doubt as to whether any facts are material, you improper claims. should disclose them. You are advised to keep a record of all information you supply to us in connection with this application, including letters. If Confidentiality: The confidentiality of patient and member information you would like a copy of this application form, please ask us. is of paramount concern to Bupa International. To this end, Bupa International fully comply with UK Data Protection Legislation and It is Bupa Internationals intention to provide a first class service to our Medical Confidentiality Guidelines. Bupa sometimes uses third parties to members at all times. However, if you have any comments or complaints, process data on its behalf. Such processing, which may be undertaken you can call the Bupa International customer helpline on outside the European Economic Area, is subject to contractual restrictions +44 (0) 1273 323 563, 24 hours a day, 365 days a year. Alternatively with regard to confidentiality and security in addition to the obligations you can email via www.bupa-intl.com/membersworld, or write to us at: imposed by the Data Protection Act. Bupa International, Russell House, Russell Mews, Brighton, BN1 2NR, UK. If we have not been able to resolve the problem and you wish to take your Medical Information: Medical information will be kept confidential. complaint further, please call Bupa International customer helpline on It will only be disclosed to those involved with your treatment or care, +44 (0) 1273 323 563, or write to our head of Customer Relations a the including your General Practitioner/Primary Health Physician, or to their above address. For hearing or speech impaired members with a textphone, agents, and, if applicable, to any person or organisation who may be please call +44 (0) 1273 866 557. We also offer a choice of Braille, large responsible for meeting your treatment expenses, or their agents. Claims print audio for our letters and literature. Please let us know which you information may also be shared with appointed third parties involved in would prefer. English Law shall apply to the agreement between you a Bupa the management and handling of your claim. Claims information may International. be discussed with the Bupa International Agent/Adviser where you have requested the Adviser to assist you. I hereby apply to be enrolled as a Member with the Dependants listed above included in my membership. I declare that to the best of my Member details: All membership documents and confirmation of how knowledge and belief the information given in this Application is true and we have dealt with any claim you may make will be sent to the principal complete. I agree that the Rules of the Bupa International scheme will be member. binding on me and all eligible Dependants included in my membership. I agree that any cover which I may purchase for the USA shall terminate Telephone calls: In the interest of continuously improving our service to upon informing Bupa International that I have become a resident of the members, your call will be recorded and may be monitored. USA. Research: Anonymised or aggregated data may be used by Bupa I confirm that I give explicit consent, within the provisions of the Data International, or disclosed to others, for research or statistical purposes. Protection Act 1998, on behalf of myself and any family members specified in this form for Bupa International to process our personal Fraud: Information may be disclosed to others with a view to preventing information with respect to our membership and I confirm that I have fraudulent or improper claims. brought the Data Protection Notice to the attention of these family members. Names and Addresses: Bupa International does not make the names Identification stamp / broker name and ID number and addresses of members or patients available to other organisations. Keeping you informed: Bupa International would, on occasion, like to keep you informed of Bupa International products and services which it considers may be of interest to you. Contact Address: If you do not wish to receive information about Bupa Internationals products and services, or have any other Data Protection for office use only queries please write to the Bupa Group Information Protection Manager, at Bupa House, 15-19 Bloomsbury Way, London WC1A 2BA or at DataProtection@Bupa .com. i m p o r t a n t i n f o r m a t i o n - Y O U R M E M B E R S H IP D E C L ARATION Please be aware that this form must be received by Bupa If we receive this form after six weeks from this declaration International no more than six weeks after the declaration date. date, or with incomplete information, we will be unable to register your details and enrol you on the plan. It is advisable that you fill in your form with complete up-to-date medical history before you sign and date this form. Please use the checklist at the front of the form to ensure you have filled everything in completely. Signature DateIN-FORM-LAF-09v2
- 9. D ata C o n s e n t F o r m If you are a member on an individual plan: If you are a member on a company plan: If you have appointed an Intermediary they will be given access to general Your intermediary has been appointed by the sponsor of your plan. As the policy and invoicing documents, eg Membership Certificate where no appointed intermediary, they will be given access to general policy and exclusions are listed, subscriptions, deductibles etc. invoicing documents, eg Membership Certificate where no exclusions are listed, subscriptions, deductibles etc. You have the option to authorise an additional level of access covering health and medical information. This access will enable your Intermediary You have the option to authorise an additional level of access covering to manage all aspects of the policy on your behalf, for example setting up health and medical information. This access will enable your Intermediary the policy, submitting and progressing claims etc. to manage all aspects of the policy on your behalf, for example setting up the policy, submitting and progressing claims etc. Yo u r c u r r e n t I n t e r m e d i a ry i s : Intermediary name Intermediary ID consent I give my consent for Bupa International to share any medical information both past, present and future with my Intermediary. This includes the following documents: Membership Certificate including any exclusions, Claim Forms and any medical information required to process any claim I may have. I am aware that this will also include any documents sent directly to Bupa International by me or my medical practitioner in respect of any treatment I may receive in the future. Signature Print name Date D D M M Y Y Reference (BI-Number or Quote Number) One consent form is required per person If you wish to cancel this authority at any time, you can do so by contacting Bupa International either by phone on +44 (0) 1273 323 563 or in writing to: Bupa International, Victory House, Trafalgar Place, Brighton. BN1 4FY. United KingdomBupa Insurance Services Ltd, Administrators, for and on behalf of your insurer. See policy documents for insurer details.FSA-GENE-DCF-11v06.1 Data Consent Form
- 10. Contact InformationPolicyholder Spouse Mr Mrs Ms Miss Other: Mr Mrs Ms Miss Other:Family Name: Family Name:Given Name: Given Name:MiddleName(s): MiddleName(s):Country: Country:Home Address: Home Address:Contact info in the country you now live in Contact info in the country you now live inMobile: Mobile:Home: Home:Work: Work:Personal email (1): Personal email (1):Personal email (2): Personal email (2):Work email: Work email:Employer: Employer:Country: Country:Employers Address: Employers Address:Permanent contact information in your home countryMobile: Country:Home: Permanent Address:Work:Emergency Contact PersonIn the event of an emergency whereby we are unable to contact you or your spouse or should you beincapacitated then please provide us with the permanent contact details of an immediate family memberwho we should contact in this situation.Family Name: Email:Given Name: Relationship to you:MiddleName(s): Country:Mobile: Home Address:Home:Work:In order to help us work with you more effectively we ask you tocomplete the following contact data sheet. By completing this fullythen we will be able to ensure you get the best possible service even though you may change your employer, country or location.Please help us by keeping us fully informed or all changes to your contact details as soon as possible. Please note all informationgiven to us is only used to help us manage your insurance policy and is never used for any other purpose.