Pacific Prime - IHI Bupa International Swiss Medical Application Form

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This is the application form for the International Swiss Medical Plan, a premier expat health insurance product offered by IHI Bupa, in partnership with Pacific Prime Insurance Brokers.

Text of Pacific Prime - IHI Bupa International Swiss Medical Application Form

  • 1. I n t e r n at i o n a l Sw iss M e d i c a l A pp l icati o n F o rm A Pacific Prime International Limited.(Please use block letters) F o r a d m i n i s t r at i o n u s e Ref. Policy Number- Date# C o m m e n c e m e n t d at e * I / we request that the policy commences fromday0 1monthyear *We will confirm to you the commencement date of your policy. Waiting periods may apply as set out in your policy conditions. Policyholder First name(s)Sex (M/F) Family name(s) Date of birth (day/month/year) Fax Email TelephoneMobile phone Address Address Postal CodeCity Country D e p e n da n t s First name(s) Date of birth (day/month/year) Family name(s) Sex (M/F) First name(s) Date of birth (day/month/year) Family name(s) Sex (M/F) First name(s) Date of birth (day/month/year) Family name(s) Sex (M/F) First name(s) Date of birth (day/month/year) Family name(s) Sex (M/F) Reimbursement via bank transfer If you would like us to transfer future reimbursements to your bank account, please state: Account holders name(s) Name of bank Bank address Postal CodeCity Country IBAN No. Swift No. Preferred reimbursement currency Please state currencyihi Bupa Customer Service Palgade 8 DK-1261 Copenhagen K Denmark Tel: +45 70 23 00 42 Fax: +45 33 32 25 60 Email: ihi@ihi.com www.ihi.com Medical Centre Tel: +45 70 23 24 60 Tel: Email: emergency@ihi.comihi Bupa is a trading name of Bupa Insurance Limited. Registered in England No. 3956433. Registered office: Bupa House, 15-19 Bloomsbury Way, London WC1A 2BA, UKBupa Insurance Limited is authorised and regulated by the Financial Services Authority (UK)

2. Pa p e r l e s s c u s t o m e r s i g n u pI hereby sign up as a paperless customer with ihi Bupa. As a paperless customer, I will receive all documents and correspondence from ihi Bupa viamy personal myPage on www.ihi.com. I understand that I will not receive any hardcopies of documents to my postal or collection address and thatit will be my responsibility to check all documents and correspondence online and to inform ihi Bupa of any changes to my email address. I can getmore information on www.ihi.com/services.I n t e r m e d i a r y s a cc e s s t o d o c u m e n t sIn the event that I am represented by an intermediary, I hereby accept that my intermediary will get access to my documents online onq his/her personal and secure ihi Bupa website.Cover please choose modules, currency and deductible by ticking the relevant boxesMain insuranceSupplementary insuranceDental & OpticalComplete Plan, deductible:Hospital Plan, deductible:CHFEUR USDCHFEUR USDMedical Evacuation& RepatriationNilNil NilNil Nil Nil300200 200600 400 400600400 4002,000 1,350 1,3502,0001,350 1,3504,000 2,700 2,700 Please note that thechosen currency is4,0002,700 2,7005,000 3,350 3,350 binding5,0003,350 3,350P r e m i u m pay m e n tAnnual Semi-annualRequest for payment from a bank or another address, if different from residential address(Not possible for paperless customers)Name(s)AddressAddressPostal Code CityCountryAccount No. (if bank)R e q u e s t f o r pay m e n t b y i n t e r n at i o n a l c r e d i t c a r dI / we wish to pay the premium via credit card. Bupa Insurance Limited (ihi Bupa) will charge the credit card directly.AmericanExpressVisa Eurocard / MastercardJCBDinersCard no.Expiry date (m/y) CVC code**CVC code: The last three/four digits after the card number on the back of the card or the last three digits in the signature field.Cardholders data if cardholder and policyholder are not the same person:Name(s)AddressAddressPostal Code CityCountry 242E3-41v1.1_ISM_ENG_App AI also authorise Bupa Insurance Limited (ihi Bupa) until further notice in writing, to charge my credit card account with unspecified amounts inrespect of my premium payments as and when these become due. ihi Bupa will inform me in advance of any premium adjustments.Cardholders signatureDate ihi Bupa Customer Service Palgade 8 DK-1261 Copenhagen K Denmark Tel: +45 70 23 00 42 Fax: +45 33 32 25 60 Email: ihi@ihi.com www.ihi.com Medical Centre Tel: +45 70 23 24 60 Tel: Email: emergency@ihi.com ihi Bupa is a trading name of Bupa Insurance Limited. Registered in England No. 3956433. Registered office: Bupa House, 15-19 Bloomsbury Way, London WC1A 2BA, UKBupa Insurance Limited is authorised and regulated by the Financial Services Authority (UK) 3. ihi Bupa M edical Q uestionnaire(Please use block letters)Please read the information regarding the underwriting conditions in Section A before completing this Medical Questionnaire. A ) U nder w ritin g C onditions Please see the below stated underwriting conditions for new applicants who would like to apply for cover and existing customers who want to apply for an upgrade in cover. Further we refer to the Policy Conditions stated in the product guide of the insurance product you are applying for. Please note that you always have to complete a Medical Questionnaire for adopted children, children born as a result of fertility treatment and children born by a surrogate mother. International Health and Hospital Plan: A Medical Questionnaire must be completed for each person aged 10 years or over applying for cover and any child under the age of 10 with a pre-existing condition or who is not in good health. All the Medical Questionnaires should be sent together with the Application Form A to the insurer. International Swiss Medical: A Medical Questionnaire must be completed for each person applying for cover. All the Medical Questionnaires should be sent together with the Application Form A to the insurer*. International Top Up Plan: A Medical Questionnaire must be completed for each person aged 16 years or over applying for cover, and any child under the age of 16 with a pre-existing condition or who is not in good health. All the Medical Questionnaires should be sent together with the Application Form A to the insurer. Superior: A Medical Questionnaire must be completed for each person aged 10 years or over applying for cover or any child under the age of 10 with a pre-existing condition or who is not in good health. All the Medical Questionnaires should be sent together with the Application Form A. Worldwide Health Insurance: A Medical Questionnaire must be completed for each person aged 16 years or over applying for cover, and any child under the age of 16 with a pre-existing condition or who is not in good health. All the Medical Questionnaires should be sent together with the Application Form A to the insurer. *Please be aware of the special underwriting condition for new applicants with a Sanitas agreement. B ) General information For administration use Policy number Date (dd/mm/yy) Broker number Applicant (Please underline the names you wish to be indicated on your insurance card. Max. 28 fields) First name(s) Family name(s) Occupation Date of birth (day/month/year)AgeSex (M/F) Nationality Other insurance Do you have a health insurance with a Bupa group company or another insurance company?YESNO Have you ever had a health insurance with a Bupa group company or another insurance company?YESNO Company name Policy number Do you intend to keep your current insurance? YESNO Have you ever had an application for health or life insurance declined or accepted subjectYESNO to exclusions or at a premium above the insurers standard rates?If yes, please enclose complete information (Policy Conditions and policy documents) Family doctor/treating physician Name Address TelephoneFax Email 4. Family nameDate of birth (dd/mm/yy)C ) M E D I C A L I N F O R M AT I O N Q U E S T I O N N A I R EThis section asks for health and medical details - known (past and present) and suspected conditions. Please tick yes or no to every question1-17 and provide answers to questions 18-22. If you tick yes to any of the questions 1-17 in this Medical Information Questionnaire, please givefull details in Section D Additional Information. Please ensure that you tell us about any known or suspected conditions and symptoms even ifprofessional advice has not yet been sought. If you already are an ihi Bupa customer and you are applying to increase cover or you are applyingto transfer from another Bupa group product, please include details of any conditions for which you have made claims since joining.1) Heart or circulatory disorders eg high blood pressure, angina/chest pains, heart attack, heart failure, abnormal heart beat, aneurysms,YES NO varicose veins, other related symptoms/diseases2) Endocrine (glandular disorders) eg obesity, thyroid problems, diabetes type 1, diabetes type 2, colitis, liver diseases, liver cirrhosis otherYES NO related symptoms/diseases3) Breathing or respiratory disorders eg asthma, COPD, shortness of breath, pneumonia, bronchitis, tuberculosis, allergies (including hayfeverYES NO and anaphylaxis), chest infections, other related symptoms/diseases4 ) Stomach, intestines, liver or gall bladder problems eg stomach inflammation/ulcers, irritable bowel, Crohns disease, colitis, cirrhosis, abdominal pain, change in bowel habits, pancreatitis, hernias, liver inflammation, gall stones, haemorrhoids/piles, otherYES NO related symptoms/diseases5) Cancer, tumours or growths eg polyps, benign growths, any cancers or pre-cancerous conditions, other symptoms/diseasesYES NO6) Skin problems eg allergic conditions, rashes, psoriasis, acne, cysts, moles that itch or bleed, dermatitis, eczema, otherYES NO related symptoms/diseases7) Brain or nervous system disorders eg stroke, dementia, migraine, repeated headaches, multiple sclerosis, nerve pain (including sciatica andYES NO shingles), epilepsy/fits, meningitis, other related symptoms/diseases8) Muscle or skeletal problems eg arthritis, back pain, neck/shoulder problems, cartilage and ligament problems, joint replacements,YES NO fractures, gout, osteoporosis, inflammatory conditions, other related symptoms/diseases9) Urinary or reproductive system problems eg kidney or