Pacific Prime - Bupa Worldwide Health Options Application Form

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    19-Jun-2015

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DESCRIPTION

one of the most comprehensive international health insurance coverage companies in the world, BUPA offers many services and options that other insurers cannot. Bupa Worldwide Health Options is their flagship International Health Insurance product, 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/

Transcript

  • 1. Joining Worldwide Health OptionsYour Application

2. i m p o r t a n t i n f o r ma t i o n To join Bupa simply complete the questions on this form. Please write clearly in BLOCK capitals using black ink.Once completed, you can email your form to newbusiness@bupa-intl.com or fax us on +44 (0) 1273 866 583 or post to Bupa International, Russell House, Russell Mews, Brighton, BN1 2NR, United Kingdom. If you feel that your email is not secure, please send us yourapplication form via post or fax. If you have faxed or emailed us then we do not need the original copy of your form.We look forward to welcoming you as a member of Bupa.For full details of terms and conditions, please see a copy of our membership guide available on request. If you have any questions when completing this form, please contact your broker or call us on +44 (0) 1273 208 181 Checklist - please make sure: you have read, signed and dated the declarationWe will not be able toprocess your application ifin section 13 this form is incomplete. the information you have given in sections 1-12is correct and complete Please be sure to check the for payments by Direct Debit or Credit Card, youhave completed the Direct Debit Instruction or the entire form.Credit Card Authoritymwhen you see this sign, it is referring to the main memberm Main member: your personal detailsm1m The date you want your cover to start: DD MM Y YYour cover cannot start before the date we receive your completed application form. TitleFirst name Other initialsFamily name Male / FemaleNationality 1st Language Occupation Date of birth DDMMYY Do you have current health cover with any other insurer, including Bupa? Yes No If Yes, please give details of your cover: Name of other health insurer How long have you been with this insurer?YYM M Name of scheme / coverMembership number Main member: your address details (please let us know straightaway about any change of address) m2m 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 / numberBuilding name / number StreetStreet Town/City Town/City Postal / zip / area codePostal / zip / area code RegionRegion 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 Are you a resident of the USA? Yes No Main member: your other contact details m3m Main contact (home) Secondary contact (work)Country codeArea code Number Country codeArea codeNumber Telephone Telephone Fax Fax MobileMobile Email Email 3. 4 Additional persons to be covered with you: personal detailsTitleFirst name 1 1st additional personOther initialsFamily nameMale / FemaleNationality1st LanguageOccupation Date of birthDD MM Y YRelationship to youTitleFirst name 2 2nd additional personOther initialsFamily nameMale / FemaleNationality1st LanguageOccupation Date of birthDD MM Y YRelationship to youTitleFirst name 3 3rd additional personOther initialsFamily nameMale / FemaleNationality1st LanguageOccupation Date of birthDD MM Y YRelationship to youTitleFirst name 4 4th additional personOther initialsFamily nameMale / FemaleNationality1st LanguageOccupation Date of birthDD MM Y YRelationship 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: Documentationm 5m If you would like to view your membership documents online via MembersWorld instead of receiving them in the post, please tell us which email address you would like us to send the link to. Please choose one of the following options: Main contact (home)Secondary contact (work) Other (below)Email: i m p o r t a n t i n f o r ma t i o nYY4. M . It is important that the information you give in sections 6, 7 and 9 matches the correct persons from sections 1 and Mu must include them tcome e tion Dg ngua ques every ected yoo to Dvant,e ou a susp ionalwas th1st L s or Ne rele th n or t tick Ye y know InternatWhat treatmen plete2 of birPleaseils ar t anpa y detaem Sections 1 and 4: Section 6:Section 7:Sectio n 4. ll us abou ady a Buteed in sure you you arealreDate Section 9:heth er anyou receiveof th going, co tonrecurr en1 ame mnamre wt did(eg very, recur)? de unsu tmen e include enperson . Please se cover an mPersonal details t n you ar trea reco y to FirsConfidential medical history d each Additional ation 4informationChoose yourionspt options page ofrycreaars. self an the next ying to in st four ye aims.6. 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Med n de ur bemem do not prred un re profes ion/procedesti bodyverin nned visir int staye Y N quumberWher ea of the Neye).of coation covee OtheYwhils .pla ersoldwid ca uto be r health an operat rance cy or aIf yo : t yonebelow hearn the ar t leg, left ceived hilstN Y Ngh Wor etshe d arspains, assu or anor ot ital, ha7 ye 1 12ent re lated ben en ed we you a doctor to hosp the last question/chestfrom n 6(eg rieatmyouthe re an emerg er receivY NHav seen ed s) in admitt lood test ms listedin ginare, an ose veins sectioYN Y N For tr e, plus re gives hether in g, whet hbeen an/bpressu Y N Y N ce ed.assuran need, win le ric emaleYimag so includnal p Y Nscl prob blood sms, or vaday-c (eg a e medica highryY N ical In aynced al le / F Ny of th ers eg sord art beat, aneu ), thyr oid e Med ent you m and adva ient, are Y Nfor anpe 2 rldwident Ma ory diheTyYNYN Wo eatm g pat Y N rculator ci ilure, abnormale 1 or ital trtreatmvisitinY N eart es (Typ , chestY NY N hosp y, cancer al or as aspital. diabet ditio 1. H , heart fain ho Y N Y N attackrders eg ma, C OPD danY Ner Surg g in hospit stay ialist) diso , asth hayfeverd to spec breathY N Y Nstayin or oration Y NY N(glandularess of ies (including s: no t neea doct e may mNal Plu u dowith pcrine shortn allergY Nese Occu NY N . Endo s, or obes itys eg n/matio in,Y edic t where yoions stay. Thes me of th butYor me M tmenth ad2rderosis flamltat ital2 be low: s, heartlem y diso bercul ach in dominal spa Y Ndwidconsu sp le. Sostay,1 1 t pain Y Nprobirator chitis, tustom , abiaWorl ecialist treau for uire a ho r examp hospital tion a/ches u: resp on ms eg el habits es or hern Y N Y Nrs yofocove o not req erapies, or aftera to yo ques ing or monia, brobleted insure,angin veins Y N Y Neath3. Br ns, pneu der pr ge in bowgall ston Y NY N For sp Plus d thre ll blad , chan cirrhosis,ical that efoshipseryd pres or varicoYN Y Nfectio xis)or ga e, colitispre-Y Ne Med tments plementa place b lationn,bloo sms,dwid 4 in hyla er es, liv s diseas inflammat io ers or ke high ryY N anap testiny cancY NY N Worl edical trea hy or com s may ta ers eg beat, aneu yroid Re hn h, in wel, Cro atitis, livers, ann2), th omac owthand m e osteopat nsultatio dent.heart 1 orType Y N Y N 4. St irritablebo iles, pancre, beni gn gr Y NY N d inclu ents or co lly indep en e,ulcers rhoids/p polypses thatY N es (Typ , chest Y N Y N or ths egs, mol treatm will be totadiabetOPD dhaem or grow, cyst Y N Y Ners eg ma, C an Y Nourss, acne many sordbreath m, asth hayfever= Main MemberY N1 = First additional personY N r, tumance condition2es, psoriasi = Second additional person Y N 3= Third additional person Y N4 = Fourth additional person ng m 5. C ous sh ed ess of ies (includi itis, ra repeater rmatraine, a andY N shortn lergers eg losis or al/ ation in, Y NY N canc ma, deecze itions , mig entia ing sciatic Y Namm ms eg, demisordory d is, tubercu omach infl minal pa do s Y N in proble allergic cond stroke pain (incl udY Neg st abits, ab or hernias egronch it lemsel hsY N Y N 6. Sk bleed, or or m diso rder y/fits,nerveY N 4. 6 Confidential medical history This 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 question for every person. If you tick Yes to a question, please give full details in Section 7 on the next page. Please ensure you tell us about any known or suspected conditions and symptoms even if professional advice has not yet been sought. If you are applying to increase cover and you are already a Bupa International member, you should also include details of any conditions for which you have made claims within the last seven years. This information will be passed to our underwriting team who will assess the terms of your plan. 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 yearsm 12 34 zz been admitted to hospital, had an operation/procedure or had an investigation m(eg a scan/blood tests) in the last seven yearsfor any of the medical problems listed in question 1 12 below: Y N Y NY NY NY 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 NY NY NY N2. Endocrine (glandular) disorders eg diabetes (Type 1 or Type 2), thyroidproblems, or obesity.Y N Y NY NY NY N3. Breathing or respiratory disorders eg shortness of breath, asthma, COPD, chestinfections, pneumonia, bronchitis, tuberculosis or allergies (including hayfever and Y N Y NY NY NY 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 NY NY NY Nhaemorrhoids/piles, pancreatitis, liver inflammation, cirrhosis, gall stones or hernias.5. Cancer, tumours or growths eg polyps, benign growths, any cancers orpre-cancerous condition. Y N Y NY NY NY N6. Skin problems eg eczema, dermatitis, rashes, psoriasis, acne, cysts, moles thatitch or bleed, or allergic conditions. Y N Y NY NY NY N7. Brain or nervous system disorders eg stroke, dementia, migraine, repeatedheadaches, multiple sclerosis, epilepsy/fits, nerve pain (including sciatica and Y N Y NY NY NY Nshingles) or meningitis.8. Muscle or skeletal problems eg arthritis, back pain, neck/shoulder problems,cartilage and ligament problems, joint replacements, fractures, osteoporosis, gout orY N Y NY NY NY 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 NY NY NY 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 NY NY NY N11. Eye, ear, nose, throat and dental problems eg cataracts, glaucoma, visualimpairment; deafness, ear infections, tonsillitis; dental infections, wisdom teeth Y N Y NY NY NY Nproblems or gingivitis.12. Psychiatric/psychological disorders eg schizophrenia, compulsive or eatingdisorders; depression, stress, anxiety or drug/alcohol dependency. Y N Y NY NY NY NPlease also answer the following questions:13. Is anyone to be covered taking any medication, prescribed or otherwise?Y N Y NY NY NY 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 pastY N Y NY NY NY 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 health care professional has Y N Y NY NY NY 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 NY NY NY N 5. 7 Additional informationThis section applies if you have indicated Yes to any questions in section 6. If you are unsure whether any details are relevant, you must include them.The relevant Please specify as accurately asWhen did the symptomsWhat treatment did you receiveWhat was the outcomequestion possible the name of the illness orstart and when was and when (please includeof the treatmentnumber medical problem. treatment completed? dates, names and details of (eg ongoing, completefrom Where applicable, please statemedications)? recovery, recurrentsection 6the area of the body affected,or likely to recur)? (eg right leg, left eye). m m1234N.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.If there is insufficient space, please use a separate sheet and indicate that you have done so by ticking this box:If you have a regular/family doctor, please fill in the below details m8 m 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. 9Choose your cov...

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