Pacific Prime - DKV Globality Health Policy Application Form

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DKV (Deutsche Krankenversicherung) Globality is one of the worlds leading international private medical insurance providers. This is the application form for their International Health Insurance product, Globailty YouGenio, offered in association with Pacific Prime Insurance Brokers. For more information, visit this page: http://www.pacificprime.com/insurers/dkv/

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  • 1. Received by Globality S.A.:Date/ Person responsibleApplication for health insuranceGlobality YouGenioGlobality S.A.13, rue Edward Steichen L-2540 LuxembourgPhone: +352 270 444 3601, e-mail: service-yougenio@globality-health.comGlobality S.A.Board of Administration: Martin von Kir, Wolfgang Diels, Horst WeberR.C.S. Luxembourg (Commercial Register): B 13447108/12

2. Globality S.A. | Application for health insurance Page 1Application for health insurance (individual insurance)I herewith apply for conclusion of a health insurance contract in accordance with Globality YouGenio for the personslisted under Person 1, 2, 3, 4.A. Particulars concerning the applicantFirst nameSurname TitleDate of birth (DD/MM/YYYY) Start date of insuranceGender NationalityOccupationProfessional statusmalefemale%XLOGLQJRRUStreet and house numberPostcode and town Country and regionMobile phone (+ country code) Fax (+ country code and local dialling code)E-mailNew (not yet customer Existing customer of Globality S.A./ Insurance No.of Globality S.A.) Correspon-Same as above %XLOGLQJ RRUStreet and house numberPostcode and town Country and region dence address Other:B. Particulars concerning the insured personsPerson First name Surname Title Hus- Non- Child Appli-Date of birth Gender Natio- Occupation Start date ofband/ marital cantmf nalityinsuranceWife partner 1 2 3 4C. Further particulars concerning the insured personsCountry of future location (whereContractual language/ languageyou will live as an expatriat):for communication: All the required information will beHome country:provided in this language.German EnglishCountry of current location (whereFrench Spanishthe application is signed): Dutch D. Plan levels and geographical areas for Globality YouGenioPerson Plan levelDeductible* Geographical area Premium (monthly) in $ 1ClassicPlus Top None250 /500 / 1000 /None USA Incl. USA325 $/650 $/ 1300 $/210 420 840 2ClassicPlus Top None250 /500 / 1000 /None USA Incl. USA325 $/650 $/ 1300 $/210 420 840 3ClassicPlus Top None250 /500 / 1000 /None USA Incl. USA325 $/650 $/ 1300 $/210 420 840 4ClassicPlus Top None250 /500 / 1000 /None USA Incl. USA325 $/650 $/ 1300 $/210 420 840 *Classic level only with a deductible of 250 / 325 US$/ 210 .Total monthly premium (for all 4 persons) 0E. Previous insuranceDo you have or have you ever had held health insurance cover in the past 5 years (including compulsory statutory/private/government insurance)?PersonInsurerInpatient Outpatient Dental Period (from to/ month-year) 1NoYes 2NoYes 3NoYes 4NoYes08/12 3. Globality S.A. | Application for health insurancePage 2F. Information on your state of health,Q RUGHU WR JHW FRPSOHWH FRYHUDJH LQFOXGLQJ SUHH[LVWLQJ FRQGLWLRQV IURP WKH VWDUW GDWH RI WKH LQVXUDQFH RX PXVW OO LQ WKH KHDOWK TXHVWLRQQDLUH EHORZ %DVHGon the answers you provide, you will be informed whether you are eligible for insurance, and whether risk loadings have to be added to the premium or whetherexclusions have to be applied to your insurance cover. , FKRVH WR JHW IXOO LQVXUDQFH FRYHU LQFOXGLQJ SUHH[LVWLQJ FRQGLWLRQV , OO LQ WKH KHDOWK TXHVWLRQQDLUH EHORZ , RSW IRU WKH PRUDWRULXP , GR QRW OO LQ WKH KHDOWK TXHVWLRQQDLUH EHORZ ,Q WKDW FDVH SUHH[LVWLQJ FRQGLWLRQV DQG WKHLU FRQVHTXHQFHV ZLOO QRW EH FRYHUHG during a qualifying period of 24 months. Please refer to pages 4 and 5 for further information on the moratorium option.Important: Please note the following (refer also to Responsibility for the information provided in the application form, page 4):All questions must be answered in detail. Symptoms, illnesses and the consequences of an accident should be mentioned even if you consider them to beunimportant. Dashes do not qualify as an answer. If you need more space: continue on a separate sheet, specifying the number of the person concerned,and refer to that sheet in your application form. If you do not wish to reveal certain information to the intermediary, this information must be provided directlyto Globality S.A. in writing within three days. In this case, you must indicate in the application form that the information is to be provided separately.If the questions on this page, where of relevance for acceptance of the risk, are answered incorrectly or incompletely, we may if the duty to provideinformation has not been wilfully violated terminate the contract within one month of being informed of the violation, insofar as we can prove that we wouldnot have insured the risk in any case. The contract shall be null and void if our assessment of the risk is affected by wilful violation of your duty to provideLQIRUPDWLRQ ,Q WKLV FDVH RX DUH REOLJHG WR UHSD WKH LQVXUDQFH EHQHWV DOUHDG UHFHLYHG :H ZLOO QRW UHIXQG WKH SDLG SUHPLXPV If insurance cover alreadyexists with Globality S.A., LW LV QRW QHFHVVDU WR VSHFLI DQ GLVRUGHUV RU FRXUVHV RI WUHDWPHQW GXULQJ WKH ODVW YH HDUV ZKLFK DUH DOUHDG IXOO NQRZQ WR*OREDOLW 6$ RQ DFFRXQW RI WKH LQYRLFHV RU PHGLFDO FHUWLFDWHV SUHVHQWHG WR *OREDOLW 6$ LQ FRQMXQFWLRQ ZLWK WKH SUHYLRXVO H[LVWLQJ LQVXUDQFH FRQWUDFWRQGLWLRQV DULVLQJ EHWZHHQ VLJQLQJ WKH DSSOLFDWLRQ IRUP DQG FRQUPDWLRQ RI DFFHSWDQFH E *OREDOLW 6$ ZLOO HTXDOO EH GHHPHG WR EH SUHH[LVWLQJ Therefore itis necessary that you advise us immediately of any material changes to the information provided, which would occur between submission of thisapplication and acceptance by us.Person 1 Person 2 Person 3 Person 4Height and weightin cm / in kgNo Yes No Yes No Yes No Yes +DYH RX EHHQ DGPLWWHG WR D KRVSLWDO WKHUDS FHQWUH KHDOWK FXUH RU VDQDWRULXP GXULQJ WKH ODVW YH HDUV +DYH RX XQGHUJRQH VXUJHU LQFOXGLQJ RXWSDWLHQW VXUJHU 4. DW DQ WLPH GXULQJ WKH ODVW YH HDUV +DYH RX UHFHLYHG SVFKRWKHUDS RU WUHDWPHQW RI DQ DGGLFWLRQ GXULQJ WKH ODVW YH HDUV4. Have you suffered any illnesses, disorders, consequences of an accident or other impairments of your health or have you undergone any examinations / treatment either during the last three years or at present?5. Do you require any kind of medication (e.g. tablets, ointments)? If yes, please specify which and what for.6. Have you been advised, or are you planning, to undergo any kind of outpatient / inpatient treatment or examination?7. Has an HIV infection ever been established (e.g. through an AIDS test)?8. Do you have impaired vision with 8 diopters or more?9. Do you have any physical / organic defect, a chronic illness, an illness or injury due to military service, any %%% % UHGXFWLRQ LQ RXU DELOLW WR ZRUNGHJUHH RI GLVDELOLW ,I HV SOHDVH HQFORVH D FRS RI WKH RIFLDO QRWLFH MonthMonthMonthMonth 10. Are you pregnant? 11. Have you visited a dentist during the last three years? 12. Are you currently receiving dental treatment, are dentures being produced or renewed, are you receiving treatment for periodontosis or orthodontic treatment, or has such treatment been recommended or planned? (If yes, an up-to-date plan of treatment and costs must be enclosed.) 13. Do you have any missing teeth which have not yet been replaced (other than milk and wisdom teeth, as well DV WHHWK IRU ZKLFK WKH JDSV KDYH EHHQ OOHG E DGMDFHQW WHHWK 5. If yes: number of missing teethFurther details concerning questions 1 9 and 12 if answered with yes:Person Ques- Type of illness, drugs, injury, symptoms, examination Treatment / symptoms Name and address of doctors, When did treat- tion(what was diagnosed?); diopter grade? Question 12:from tohospitals; who can provide further ment / symptoms which treatment?(month-year) information? cease?Please specify the name and address of your family doctor or other doctor best able to provide further information concerningyour health:G. Special agreements* and remarks*6XEMHFW WR ZULWWHQ FRQUPDWLRQ E *OREDOLW 6$08/12 6. Globality S.A. | Application for health insurance Page 3 H. Payment of premiums Payment frequencymonthlyquarterlyhalf-yearlyyearly Payment methodPremium to be remitted to Globality S.A.BGL BNP Paribas IBAN: LU090030309301020000 WL BIC Code BGLLLULLCredit CardVisaMasterCardTogether with your welcome package, you will receive a link to a special secure webpage, where you will be ableto enter your credit card details in order to active your insurance cover.Please note that the following surcharges are due on the premium for the respective intervals:0% for yearly payment, 2% for half-yearly payment, 3% for quarterly payment and 4% for monthly payment.Direct Debit for Luxembourg bank accounts (use separate form)Direct Debit for German bank accounts (when different from reimbursement account, use separate form)2QH DFFRXQW PXVW EH VSHFLHG IRU UHLPEXUVHPHQWV E WKH LQVXUHU LI DYDLODEOH Account holder Name of bank Account No.Branch No. (BLZ) Postcode / TownCountry Swift (BIC)IBAN I. Final provisionsPlease check that the information provided in this application form is correct and complete.By signing this form,To be completed by the intermediary: When answering the questions in thisI also give my consent to the receipt, storage, processing and transmission of personal data form, did the applicant provide informa-and give mandate to provide medical information (in some jurisdictions referred to as releasetion which has not been recorded in thisIURP WKH SURIHVVLRQDO FRQGHQWLDOLW GXW 7. DV GHWDLOHG RQ SDJH, JLYH WKLV FRQVHQW IRU PVHOIapplication form? No Yesfor my insured children and for the coinsured persons I represent by law.I do not give mandate to professionals to provide Globality S.A. with information on my health If yes, which?and treatment as detailed on page 4. I wish to be informed by the insurer, which persons andinstitutions information is required from. I will then decide in each instance whether or not I willJLYH PDQGDWH WR WKH VSHFLHG SHUVRQV RU LQVWLWXWLRQV WR IRUZDUG LQIRUPDWLRQ WR *OREDOLW 6$If I choose this alternative,1. conclusion of the insurance contract which I have requested may be delayed or denied, if theremaining sources of information do not make it possible to investigate and assess the