Pacific Prime - Bupa Worldwide Health Options Application Form
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Pacific Prime - Bupa Worldwide Health Options Application Form

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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 ...

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/

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Pacific Prime - Bupa Worldwide Health Options Application Form Pacific Prime - Bupa Worldwide Health Options Application Form Document Transcript

  • Joining Worldwide Health OptionsYour Application
  • 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 your application 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 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 m when you see this sign, it is referring to the main member m 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 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? Y Y M M Name of scheme / cover Membership number 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     Are you a resident of 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
  • 4 Additional persons to be covered with you: personal details 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: Documentation m 5 m 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 n Y Y 4. 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 D g ngua ques every ected yo o to D vant, e ou a susp ional was th 1st L s or N e rele th n or t tick Ye y know Internat What treatmen plete 2 of bir Please ils ar t an pa y deta e m Sections 1 and 4: Section 6: Section 7: Sectio n 4. ll us abou ady a Bu te ed in sure you you are alre Date Section 9: heth er an you re ceive of th going, co t on recurr en 1 ame m nam re w t did (eg very, recur)? d e unsu tmen e include en person . Please se cover an m Personal details t n you ar trea reco y to Firs Confidential medical history d each Additional ation 4 information Choose yourions pt options page of ry crea ars. self an the next ying to in st four ye aims. 6. If What hen (pleas d details or lik el histo ction ber to ver o t your s l abou ction 7 on pl la are ap ithin the ying your 3cl in se ptom and w names an edica d pres ent ils in Se ht. If you ims w om pa form qu N y Y es tions did th e sym ur co s, date ations)? mem Each utomati c e al m st an full deta en soug made cla us fr l in2 was se yo y nam io a When d when eted? denti ils, pa ve l deta please gi s not yet be ve you ha or it may stop it1 n ‘Y N d Y es ’ to an Choo medic a plan dwide M Confi an pl m Add start ent com Famil edica n, ha and m a questio l advice ons for w ur cove hich r e N dicate ly as avY in curate N s or treatm Worl er. Ple Title alth 6 n asks you na for he tick Yes to professio y conditi rminate yo m7 ies ifN you h as ac the illnes ify N of Y 9 or as a cov if an te Y spec ight sectio rson. If oms even details of we may n appl Please le the Y am . e overn core d fo nce to ad This ion n ery pe sympt so inclu de tails years stigat Y N sectio state ther Y N sura p: wish t full de ital, ei This ib for ev ons and ould al bershi e last 3 d an inve levan poss al problem , please ed, ntial ical In with mem The reYonN hosp itials iti th ha ct N cond r, you sh ovide us r the sional in e or ic le affe g esse med applicab Y ing in ality t. Med n de ur be mem do not pr red un re profes ion/proced esti body verin nned visi r in t stay e Y N quumber Wher ea of the Neye). of co ation cove e Othe Y whils . pla erso ldwid ca u to be r health an operat rance cy or a If yo : t yone below hear n the ar t leg, left ceived hilst N Y Ngh Wor efits he d ars pains, assu or an or ot ital, ha 7 ye 1 – 12 ent re lated ben en ed w e you a doctor to hosp the last question /chest from n 6 (eg ri eatm you the re an emerg er receiv Y N Hav seen ed s) in admitt lood test ms listed in gina re, an ose veins sectioY N Y N For tr e, plus re gives hether in g, whet h been an/b pressu Y N Y N ce ed. as suran need, w in le ric emaleY imag so includ nal p Y N sc l prob blood sms, or va day-c (eg a e medica high ry Y N ical In ay nced al le / F N y of th ers eg sord art beat , aneu ), thyr oid e Med ent you m and adva ient, are Y N for an pe 2 rldwid ent Ma ory di he Ty Y N Y N Wo ea tm g pat Y N rculat or ci ilure, abno rmal e 1 or ital tr treatm visitin Y N eart es (Typ , ches t Y N Y N hosp y, cancer al or as a spital . diabet ditio 1. H , heart fa in ho Y N Y N attack rder s eg ma, C OPD d an Y N er Surg g in hosp it stay ialist ) diso , asth hayfever d to spec breath Y N Y N stayin or or ation Y N Y N (gland ular ess of ies (includ ing s: no t nee a doct e may mN al Plu u do with p crine shortn allerg Y N ese Occu N Y N . Endo s, or obes ity s eg n/ matio in, Y edic t where yo ions stay. Thes me of th but Y or m e M tmen th ad 2 rder osis flam ltat ital 2 be low: s, hea rt lem y diso bercul ach in dominal s pa Y N dwid consu sp le. So stay, 1 1 t pain Y N prob irator chitis, tu stom , ab ia Worl ecialist trea u for uire a ho r examp hospital tion a/ches u: resp on ms eg el habits es or hern Y N Y N rs yo fo cove o not req erapies, or after a to yo ques ing or monia, br obleted in sure, angin veins Y N Y N eath 3. Br ns, pneu der pr ge in bo w gall st on Y N Y N For sp Plus d th re ll blad , chan cirrhosis, ical that efo ship se ry d pres or varico Y N Y N fectio xis) or ga e, colitis pre- Y N e Med tments plementa place b lation n, bloo sms, dwid 4 in hyla er es, liv ’s diseas inflammat io ers or ke high ry Y N anap testin y canc Y N Y N Worl edical trea hy or com s may ta ers eg beat, aneu yroid Re hn h, in wel, Cro atitis, liver s, an n 2), th omac owth and m e osteopat nsultatio dent. heart 1 or Type Y N Y N 4. St irritable bo iles, pa ncre , beni gn gr Y N Y N d inclu ents or co lly indep en e , ulcers rhoids/p polyps es th at Y N es (Typ , ches t Y N Y N or ths eg s, mol treatm will be to ta diabet OPD d haem or gr ow , cyst Y N Y N ers eg ma, C an Y N ours s, acne man y sord breath m , asth hayfever = Main Member Y N 1 = First additional person Y N r, tum ance condition 2 es, ps oriasi = Second additional person Y N 3 = Third additional person Y N 4 = Fourth additional person ng m 5. C ous sh ed ess of ies (includi itis, ra repeat er rmat raine, a and Y N shortn lerg ers eg losis or al / ation in, Y N Y N canc ma, de ecze itions , mig entia ing sciatic Y N amm ms eg , dem isordory d is, tuberc u omac h infl minal pa do s Y N in pr oble allergic co nd stroke pain (incl ud Y N eg st abits, ab or hernia s egronch it lems el h s Y N Y N 6. Sk bleed, or or m di so rder y/fits, nerve Y N
  • 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 years m 1 2 3 4 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 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, Crohn’s 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 hernias.5. Cancer, tumours or growths eg polyps, benign growths, any cancers orpre-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 meningitis.8. 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 health care 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
  • 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 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 6 the area of the body affected, or likely to recur)? (eg right leg, left eye). m m 1 2 3 4N.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 m 8 m Doctor’s 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:
  • 9 Choose your cover options m 1 2 3 4 m Worldwide Medical Insurance For treatment received whilst staying in hospital, either overnight or as a Each member to be included on this plan day-case, plus related benefits. automatically receives cover for Worldwide Medical Insurance, our core cover. Please Worldwide Medical Insurance gives you the reassurance of covering essential hospital treatment you may need, whether in an emergency or a planned visit. Surgery, cancer tick the options you wish to add for you and treatment and advanced imaging, whether received whilst staying in hospital or as a any additional people. visiting patient, are also included. Worldwide Medical Plus: For specialist treatment where you do not need to stay in hospital. Worldwide Medical Plus covers you for consultations with a doctor or specialist and medical treatments that do not require a hospital stay. These may include osteopathy or complementary therapies, for example. Some of these treatments or consultations may take place before or after a hospital stay, but many will be totally independent. Worldwide Medicines and Equipment: For prescribed medicines and medical equipment. Often, treatment does not end when you leave the hospital or clinic or after you have seen a specialist. This option covers you for prescription medicines and the rental of medical appliances, such as oxygen supplies or wheelchairs. Our unique benefit for long- term prescriptions will also pay for any medicine required to manage chronic conditions such as asthma. Worldwide Wellbeing: For a range of health screenings, vaccinations, dental and optical treatment. Our Wellbeing option is designed to help you protect and maintain your health. It covers medical screenings that can provide valuable early detection of conditions such as cancer. It covers dental and optical treatments, which can play an important role in keeping you healthy by identifying underlying problems such as mouth cancer or diabetes. Worldwide Evacuation: For when you can’t get the treatment you need in a local hospital. The Worldwide Evacuation option covers you for reasonable transport costs to the nearest suitable medical centre, when the treatment you need is not available nearby. Repatriation, which is also included, gives you the added option of returning to your home country or specified country of nationality, to be treated in familiar surroundings. Cover for pre-existing conditions: If you have a pre-existing medical condition, this option could provide you with the This option will apply to each member opportunity to be covered for it. If you would like to find out if we can cover you and to to be included on this plan obtain a quote, please tick here. If your plan includes cover for pre-existing conditions, this cover does not apply in the USA. USA cover: If you spend most of your time in the USA, then you will need to buy USA cover on an annual basis. If you spend most of your time outside the USA, you can choose to add USA cover to your plan by ticking in this section. Please note, we do not cover permanent USA residents. This cover will increase your premium. If your plan includes cover for pre-existing conditions, this cover does not apply in the USA. 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. If you choose any of the deductible amounts on Worldwide Medical Insurance then a fixed deductible amount of £100 ($170 / ¤125) is applied to Worldwide Medical Plus and £50 ($80 / ¤60) fixed deductible amount is applied to Worldwide Medicines and Equipment (if you choose these options). The deductible you choose will apply to each member on this form. GBP: None £250 £500 £1000 £2000 £5000 USD: None $425 $850 $1700 $3400 $8500 EUR: None ¤300 ¤625 ¤1250 ¤2500 ¤6250Please refer to the membership guide for full details.
  • 10 Your payment details (Direct debit, credit card or cheque/bankers draft) Your choice of currency for your cover and subscription payments (please tick one only):  GBP(£) USD($) EUR(¤) How will you make your subscription payments (please tick one only): Monthly Quarterly Yearly You must choose to pay by direct debit or credit card if you have chosen a deductible. 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: Please note, when choosing to pay via cheque or bankers draft, you can not pay monthly or have a deductible. Please fill in the name of the person paying the subscription in the box provided below when choosing to pay via cheque or bankers draft. Name: 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: Account holder’s signature Date Reference number (for Bupa International use only) BI - - - Originator’s 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. Cardholder’s name as it appears on the card: Card number: Valid from date: Expires/end date: - - - / / Cardholder’s signature Date zz This Guarantee is offered by all banks and building societies that take part zz If an error is made by Bupa International or your Bank or Building Society, youThe Direct Debit Guarantee in the Direct Debit Scheme. The efficiency and security of the Scheme is are guaranteed a full and immediate refund from your branch of the amountThis guarantee should be detached and retained by the payer monitored and protected by your own Bank or Building Society. paid. zz If the amounts to be paid or the payment dates change, Bupa International zz You can cancel a Direct Debit at any time by writing to your Bank or Building will notify you 7 working days in advance of your account being debited or as Society. Please also send a copy of your letter to us. otherwise agreed.
  • 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, your Benefits may not be payable if you do not fully disclose any material facts family, will be used by Bupa International to process your claims, administer which could influence our assessment and acceptance of this application your policy and may be used to detect and prevent fraud or improper and, if you are in any doubt as to whether any facts are material, you 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 you Confidentiality: The confidentiality of patient and member information is would like a copy of this application form, please ask us. of paramount concern to Bupa International. To this end, Bupa International fully comply with UK Data Protection Legislation and Medical Confidentiality It is Bupa International’s intention to provide a first class service to our Guidelines. Bupa sometimes uses third parties to process data on its behalf. members at all times. However, if you have any comments or complaints, Such processing, which may be undertaken outside the European Economic you can call the Bupa International customer helpline on Area, is subject to contractual restrictions with regard to confidentiality and +44 (0)1273 323 563, 24 hours a day, 365 days a year. Alternatively security in addition to the obligations imposed by the Data Protection Act. you can email via www.bupa-intl.com/membersworld, or write to us at: Bupa International, Russell House, Russell Mews, Brighton, BN1 2NR, UK. If Medical information: Medical information will be kept confidential. It will you have not received a response within 8 weeks or you remain unhappy only be disclosed to those involved with your treatment or care, including with our final response, you may refer your complaint to the Financial your General Practitioner/Primary Health Physician, or to their agents, and, Ombudsman Service. Their address and contact details are: South Quay if applicable, to any person or organisation who may be responsible for Plaza, 183 Marsh Wall, London E14 9SR, telephone; 0845 080 1800 meeting your treatment expenses, or their agents. Claims information may or +44 (0) 207 964 1000 from outside the UK. For hearing or speech also be shared with appointed third parties involved in the management impaired members with a textphone, please call +44 (0) 1273 866 557. and handling of your claim. Claims information may be discussed with the We also offer a choice of Braille, large print audio for our letters and Bupa International Agent/Adviser where you have requested the Adviser to literature. Please let us know which you would prefer. English Law shall apply assist you. to the agreement between you and Bupa International. Member details: All membership documents and confirmation of how I hereby apply to be enrolled as a Member with the Dependants listed we have dealt with any claim you may make will be sent to the principal above included in my membership. I declare that to the best of my member. knowledge and belief the information given in this Application is true and complete. I agree that the Rules of the Bupa International scheme will be Telephone calls: In the interest of continuously improving our service to binding on me and all eligible Dependants included in my membership. members, your call will be recorded and may be monitored. I agree that any cover which I may purchase for the USA shall terminate upon informing Bupa International that I have become a resident of the Research: Anonymised or aggregated data may be used by Bupa USA. International, or disclosed to others, for research or statistical purposes. I confirm that I give explicit consent, within the provisions of the Data Fraud: Information may be disclosed to others with a view to preventing Protection Act 1998, on behalf of myself and any family members specified fraudulent or improper claims. in this form for Bupa International to process our personal information with respect to our membership and I confirm that I have brought the Data Names and addresses: Bupa International does not make the names and Protection Notice to the attention of these family members. 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 International’s products and services, or have any other Data Protection queries please write to the Head of Information Governance, at Bupa House, 15-19 Bloomsbury Way, London WC1A 2BA or at DataProtection@Bupa.com. for office use only Identification stamp / broker name and ID number m i m p o r t a n t i n f o r ma t i o n - Y O U R M E M B E R S H IP D E C L A R A TI O N m Please be aware that this form must be received by Bupa If we receive this form after six weeks from this signed International no more than six weeks after the declaration date. declaration 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 on the front of the form to ensure you have filled everything in completely.IN-BWHO-E81-10.v10.2 BWHO ApplicationForm ML Signature Date
  • 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
  • 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.