- 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:
[email protected] 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
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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
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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$
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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
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information do not make it possible to investigate and assess the
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and documents regarding my policy will be sent: to my
correspondence address to the following intermediary to whom I give
mandate to receive them on my behalf:I herewith agree that
information on special offers by Globality S.A. may be sent to me
in writing and by telephone. Yes NoThis consent may be revoked at
any time.By signing this form, I also give my consent to all
declarations printed on pages 4 and 5 (including the declaration
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/X[HPERXUJ 12. %9$7 /8 13. Globality S.A. | Application for health
insurance Page 4Declarations by the applicant and person(s) to be
co-insuredThe following points are known to me:who are named in the
documents presented to Globality S.A. or were involved in the
medical treatment, to provide Globality S.A.Right of withdrawalwith
information on my health and treatment in order to permitYou may
withdraw your application for health insurance in writingassessment
of the medical risk when concluding the contract andwithin 14 days
without specifying any reasons. The time-limit be-YHULFDWLRQ RI P
ULJKWV XQGHU WKH LQVXUDQFH FRQWUDFWgins to run on the day on which
you receive your insurance policyand the General Conditions of
Insurance. For compliance with thisBy signing this application for
health insurance, I also give appro-GHDGOLQH LW LV VXIFLHQW WR VHQG
RXU QRWLFH RI ZLWKGUDZDO E SRVW priate mandate to allow Globality
S.A. to provide information onemail or fax before it expires. Your
withdrawal should be ad-my health and treatment or on my insurance
cover to other com-dressed to Globality S.A., 13, rue Edward
Steichen, L-2540 Lux-panies in the Mnchener
Rckversicherungs-Gesellschaft AG, theembourg. If you send your
withdrawal by e-mail or fax, pleasereinsurer group, to contracted
medical providers and to partnerssend it to:
[email protected] with Globality
S.A.. This mandate is revocable at any+352 / 270 444 3699. time.
Globality S.A. undertakes to provide such information to third
parties exclusively for the purpose of the performance
ofConsequences of withdrawal the insurance contract, the granting
of the insurance cover andIf you validly exercise your right of
withdrawal, the premiums the provision of assistance services,
advice and support.DQG EHQHWV UHFHLYHG PXVW EH UHWXUQHG E WKH
UHVSHFWLYH SDUWLHVIf you have agreed to inception of the insurance
cover before7KH PDQGDWH DV GHQHG DERYH VKDOO FRQWLQXH WR DSSO DIWHU
Pexpiry of the period for withdrawal, we are only obliged to refund
death, and be valid for my insured children and any other
insuredthe premium corresponding to the period following the
receipt of persons whom I represent by law.your notice of
withdrawal. I also agree, subject to revocation at any time, that
GlobalityAcceptation of your application for health insurance S.A.
may obtain information from the Register of Companies,The
application for health insurance does not commit the ap- the
Register of Debtors and the Register of Private
Insolvencies,plicant or the insurer to conclude the insurance
contract. The either directly or through credit reporting agencies,
in order toinsurer is obliged, subject to payment of damages, to
notify the assess my creditworthiness.applicant, within thirty days
from the receipt of the application,an offer for insurance, the
conditioning of the insurance to a Start date of insurance
coverfurther enquiry, or a refusal. ,QVXUDQFH FRYHU FRPPHQFHV RQ
WKH GDWH VSHFLHG LQ WKH LQVXU- ance policy (start date of
insurance), but not before payment ofResponsibility for the
information provided in the WKH UVW SUHPLXP DQG QRW EHIRUH H[SLU RI
DQ TXDOLILQJ SHULRGVapplicationInsured events occuring before the
start date of the insurance ZLOO QRW EH LQGHPQLHG ,QVXUHG HYHQWV
RFFXULQJ DIWHU FRQFOXVLRQBefore declaring my intention to conclude
a contract, I must in- of the insurance contract but before the
start date of the insur-form the insurer of all circumstances known
to me and requestedance are excluded. If the contract is amended,
the provisions ofby the insurer, which are of importance for the
insurers decision this paragraph will apply to the new, additional
part of the insur-to provide the agreed insurance cover. ance
cover.Attention is drawn to the information given on page 2 with
regardGoverning documentsto the legal consequences of incorrectly
answering the questions The insurance contract will be governed by
the General Condi-concerning your state of health. tions of
Insurance for Globality YouGenio.Applicable law A copy of the
application form will be handed over to me as soonThe insurance
contract will be governed by the provisions of the as I have signed
it.law of the Grand Duchy of Luxembourg insofar as another
ap-plicable law according to national regulations does not
containValidity of the contractprovisions incompatible with the
provisions of the law of theThe insurance contract is only valid
when the application hasGrand Duchy of Luxembourg. been accepted by
the insurer in writing and the insurance policy KDV EHHQ LVVXHG
3DPHQW RI WKH UVW SUHPLXP WR WKH LQWHUPHGL-Supervisory authorityary
does not constitute acceptance of the application.Complaints may be
addressed to Globality S.A. or to theombudsman for insurance
companies (A.C.A. Association desXH SDPHQW RI WKH UVW
SUHPLXPCompagnies dAssurance in collaboration with the U.L.C. 7KH
UVW SUHPLXP RU SUHPLXP LQVWDOPHQW LV GXH DV VRRQ DV ZHUnion
Luxembourgeoise des Consommateurs) or to the super-have accepted
your application for insurance. The premium isvisory authority for
the insurance sector in Luxembourg, the owed by you; it is your
responsibility to ensure punctual pay-Commissariat aux Assurances.
ments.Consent to the receipt, storage, processing and transmis-Term
of the contractsion of personal dataThe insurance contract is
initially concluded for a duration ofBy signing this application
for health insurance, I explicitly agree one year which is
automatically renewed for further periods ofto the receipt, storage
and processing of my personal, insur-12 months each on expiry of
each year, unless you object to theance, health data and bank
details by Globality S.A., and to renewal not less than three
months before expiry of the insur-the transmission thereof to other
companies in the Mnchener ance year.Rckversicherungs-Gesellschaft
AG, the reinsurer group, tocontracted medical providers and to
partners cooperating withMoratoriumGlobality S.A.. Globality S.A.
undertakes to collect, store, process 7KH PRUDWRULXP LV GHQHG DV D
TXDOLILQJ SHULRG RIPRQWKVand transmit such data and details to
third parties exclusively forduring which treatment costs
attributable to pre-existing medicalthe purpose of the performance
of the insurance contract, theconditions and their consequences are
excluded from the insur-granting of the insurance cover and the
provision of assistanceance cover. After a continuous insurance
period of 24 months,services, advice and support.we will reimburse
the eligible expenses incurred for pre-existing medical conditions
and their consequences if the insured person,QIRUPDWLRQ FRQFHUQLQJ
WKH LGHQWLW DQG UHJLVWHUHG RIFH RI WKLUGdid not suffer any symptoms
and did not require treatment, didparties processing my data is
available from Globality S.A. on not consult a doctor and did not
receive or require any medica-request at any time. tion in relation
to pre-existing medical conditions or their conse- quences during
this 24-month period. The moratorium may beThis consent shall
continue to apply after my death, and be validextended beyond the
24 months for those disorders which werefor my insured children and
any other insured persons whom I QRW ZLWKRXW VPSWRPV RU WUHDWPHQW
GXULQJ WKH UVWPRQWKVrepresent by law. Conversion:, KDYH D ULJKW RI
DFFHVV DQG UHFWLFDWLRQ WR P SHUVRQDO GDWD RQ - General Conditions
of Insurance for Globalityrequest at any time. YouGenio In cases of
conversion of a health insurance contract (e.g.Mandate to provide
medical information FKDQJH RI SODQ OHYHOV 14. WKH SODQ IHDWXUHV
VSHFLHG LQ WKHBy signing this application for health insurance, I
give appropri- General Conditions of Insurance for the Globality
YouGenioate mandate to allow doctors, nurses and other medical
staff, as shall apply for the new plan level as from the date of
con-well as employees of hospitals, clinics, nursing homes,
privateYHUVLRQ VSHFLHG LQ WKH HQGRUVHPHQW WR WKH LQVXUDQFH
SROLFinsurance companies, statutory health insurance
institutions,Depending on the agreed plan level, the qualifying
periodsemployers liability insurance associations and public
authoritieswill also apply accordingly for the additional insurance
cover.08/12 15. Globality S.A. | Application for health
insurancePage 5- Right of withdrawallllnesses and their
consequences, as well as the conse-The previous insurance cover
shall continue to apply if aquences of accidents which have
occurred during the previ-requested conversion does not become
effective because ous insurance term and which constitute an
increased riskthe right of withdrawal has been exercised.DFFRUGLQJ
WR PHGLFDO QGLQJV PD EH H[FOXGHG IURP WKH higher insurance cover.-
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credited to the new This also includes the treatment and delivery
associatedinsurance following conversion.with an existing
pregnancy.Insurance cover may be increased during an insurance
year;Persons eligible for insurancereductions in insurance cover
are only possible with effect As someone who is temporarily living
abroad for at least threefrom the beginning of the next insurance
year.PRQWKV , FRQUP EHLQJ HOLJLEOH IRU LQVXUDQFH RU WKDW , ZLOO
EHeligible on the start date of the insurance cover. I am aware
that- Insurance yearfamily members / my non-marital partner can
only be co-insuredThe insurance year shall remain unchanged
following con-to the extent that they are eligible for insurance
under the provi-version.sions of the General Conditions of
Insurance; they are not co-insured automatically.- Surcharges for
substandard risk, restrictions, ex-clusionsPrevious insuranceIf
surcharges were payable for substandard risk prior toYou need to
provide Globality S.A. with your previous healthconversion of the
insurance, these surcharges shall also be insurance or state
healthcare system details of the past 5 yearslevied on the new plan
premiums at the same percentage(including compulsory
statutory/private/government insurance)rates unless agreed
otherwise. The surcharges will change for inpatient, outpatient and
dental cover.to the same extent that premiums change (e.g. due to
ad-justment except when changing to the next age group).Any
restrictions on insurance cover and exclusions fromEHQHWV
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