Received by Globality S.A.:Date/ Person responsibleApplication for health insuranceGlobality YouGenio®Globality S.A.13, ru...
Globality S.A. | Application for health insurance                                                                         ...
Globality S.A. | Application for health insurance                                                                         ...
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Globality S.A. | Application for health insurance                                                                         ...
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Pacific Prime - DKV Globality Health Policy Application Form

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DKV (Deutsche Krankenversicherung) Globality is one of the world’s 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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Pacific Prime - DKV Globality Health Policy Application Form

  1. 1. Received by Globality S.A.:Date/ Person responsibleApplication for health insuranceGlobality YouGenio®Globality 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 Kiær, Wolfgang Diels, Horst WeberR.C.S. Luxembourg (Commercial Register): B 13447108/12
  2. 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 name Surname Title Date of birth (DD/MM/YYYY) Start date of insuranceGender Nationality Occupation Professional status male female%XLOGLQJÀRRU Street and house number Postcode and town Country and regionMobile phone (+ country code) Fax (+ country code and local dialling code) E-mail New (not yet customer Existing customer of Globality S.A./ Insurance No. of Globality S.A.) Correspon- Same as above %XLOGLQJ ÀRRU Street and house number Postcode 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 of band/ marital cant m f nality insurance Wife partner 1 2 3 4C. Further particulars concerning the insured personsCountry of future location (where Contractual 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 (where French Spanishthe application is signed): Dutch ®D. Plan levels and geographical areas for Globality YouGenioPerson Plan level Deductible* Geographical area Premium (monthly) in € $ £ 1 Classic Plus Top None 250 €/ 500 €/ 1000 €/ None USA Incl. USA 325 $/ 650 $/ 1300 $/ 210 £ 420 £ 840 £ 2 Classic Plus Top None 250 €/ 500 €/ 1000 €/ None USA Incl. USA 325 $/ 650 $/ 1300 $/ 210 £ 420 £ 840 £ 3 Classic Plus Top None 250 €/ 500 €/ 1000 €/ None USA Incl. USA 325 $/ 650 $/ 1300 $/ 210 £ 420 £ 840 £ 4 Classic Plus Top None 250 €/ 500 €/ 1000 €/ None USA Incl. USA 325 $/ 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)?Person Insurer Inpatient Outpatient Dental Period (from – to/ month-year) 1 No Yes 2 No Yes 3 No Yes 4 No Yes08/12
  3. 3. Globality S.A. | Application for health insurance Page 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 EHQH¿WV 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 FHUWL¿FDWHV SUHVHQWHG WR *OREDOLW 6$ LQ FRQMXQFWLRQ ZLWK WKH SUHYLRXVO H[LVWLQJ LQVXUDQFH FRQWUDFWRQGLWLRQV DULVLQJ EHWZHHQ VLJQLQJ WKH DSSOLFDWLRQ IRUP DQG FRQ¿UPDWLRQ 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 4 Height and weight in cm / in kg No 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. 4. DW DQ WLPH GXULQJ WKH ODVW ¿YH HDUV +DYH RX UHFHLYHG SVFKRWKHUDS RU WUHDWPHQW RI DQ DGGLFWLRQ GXULQJ WKH ODVW ¿YH HDUV 4. 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 ZRUN GHJUHH RI GLVDELOLW ,I HV SOHDVH HQFORVH D FRS RI WKH RI¿FLDO QRWLFH Month Month Month Month 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. 5. If yes: number of missing teeth Further 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 – to hospitals; 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 FRQ¿UPDWLRQ E *OREDOLW 6$08/12
  6. 6. Globality S.A. | Application for health insurance Page 3 H. Payment of premiums Payment frequency monthly quarterly half-yearly yearly Payment method Premium to be remitted to Globality S.A. BGL BNP Paribas · IBAN: LU090030309301020000 · WL BIC Code BGLLLULL Credit Card Visa MasterCard Together with your welcome package, you will receive a link to a special secure webpage, where you will be able to 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 VSHFL¿HG IRU UHLPEXUVHPHQWV E WKH LQVXUHU LI DYDLODEOH Account holder Name of bank Account No. Branch No. (BLZ) Postcode / Town Country 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 this I 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 release tion which has not been recorded in this IURP WKH SURIHVVLRQDO FRQ¿GHQWLDOLW GXW
  7. 7. DV GHWDLOHG RQ SDJH , JLYH WKLV FRQVHQW IRU PVHOI application form? No Yes for 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 and institutions information is required from. I will then decide in each instance whether or not I will JLYH PDQGDWH WR WKH VSHFL¿HG 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 the remaining sources of information do not make it possible to investigate and assess the risk. LW PD WDNH ORQJHU WR LQYHVWLJDWH P FODLPV EHQH¿WV PD EH UHGXFHG RU WKH LQVXUHU PD EH UHOLHYHG IURP LWV REOLJDWLRQ WR SD EHQH¿WV LI WKH REOLJDWLRQ WR SD EHQH¿WV FDQQRW EH IXOO established on the basis of the remaining sources of information.All information 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 No This 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 concerningP ULJKW RI ZLWKGUDZDO DQG GDWD SURWHFWLRQ
  8. 8. DQG FRQ¿UP KDYLQJ UHDG DQG XQGHUVWRRG WKH *HQHUDO RQGLWLRQV RI ,QVXUDQFH IRUGlobality YouGenio®.Place and date Signature of the applicant Signature of intermediaryIntermediary name and No. Sub-intermediary 1 name and No. Sub-intermediary 2 name and No.Signature(s) of the co-insured person(s) or their legal representative(s)08/12
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  13. 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 withdrawal with information on my health and treatment in order to permitYou may withdraw your application for health insurance in writing assessment of the medical risk when concluding the contract andwithin 14 days without specifying any reasons. The time-limit be- YHUL¿FDWLRQ 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 this By signing this application for health insurance, I also give appro-GHDGOLQH LW LV VXI¿FLHQW 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 Münchener Rückversicherungs-Gesellschaft AG, theembourg. If you send your withdrawal by e-mail or fax, please reinsurer group, to contracted medical providers and to partnerssend it to: service-yougenio@globality-health.com cooperating 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 EHQH¿WV UHFHLYHG PXVW EH UHWXUQHG E WKH UHVSHFWLYH SDUWLHVIf you have agreed to inception of the insurance cover before 7KH PDQGDWH DV GH¿QHG 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 VSHFL¿HG 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 SHULRGVapplication Insured events occuring before the start date of the insurance ZLOO QRW EH LQGHPQL¿HG ,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 requested ance are excluded. If the contract is amended, the provisions ofby the insurer, which are of importance for the insurer’s 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 regard Governing 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 contain Validity of the contractprovisions incompatible with the provisions of the law of the The 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 authority ary 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 des XH SDPHQW RI WKH ¿UVW SUHPLXPCompagnies d’Assurance – 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 data The 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 Münchener ance year.Rückversicherungs-Gesellschaft AG, the reinsurer group, tocontracted medical providers and to partners cooperating with MoratoriumGlobality S.A.. Globality S.A. undertakes to collect, store, process 7KH PRUDWRULXP LV GH¿QHG DV D TXDOLILQJ SHULRG RI PRQWKVand transmit such data and details to third parties exclusively for during which treatment costs attributable to pre-existing medicalthe purpose of the performance of the insurance contract, the conditions and their consequences are excluded from the insur-granting of the insurance cover and the provision of assistance ance 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 RI¿FH RI WKLUG did 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 valid extended 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 ¿UVW PRQWKVrepresent by law. Conversion:, KDYH D ULJKW RI DFFHVV DQG UHFWL¿FDWLRQ 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. 14. WKH SODQ IHDWXUHV VSHFL¿HG LQ WKHBy signing this application for health insurance, I give appropri- General Conditions of Insurance for the Globality YouGenio®ate 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, private YHUVLRQ VSHFL¿HG 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 authorities will also apply accordingly for the additional insurance cover.08/12
  15. 15. Globality S.A. | Application for health insurance Page 5 - Right of withdrawal lllnesses and their consequences, as well as the conse- The previous insurance cover shall continue to apply if a quences of accidents which have occurred during the previ- requested conversion does not become effective because ous insurance term and which constitute an increased risk the right of withdrawal has been exercised. DFFRUGLQJ WR PHGLFDO ¿QGLQJV PD EH H[FOXGHG IURP WKH higher insurance cover. - Crediting of the prior term The term of the prior insurance shall be credited to the new This also includes the treatment and delivery associated insurance following conversion. with an existing pregnancy. Insurance cover may be increased during an insurance year; Persons eligible for insurance reductions in insurance cover are only possible with effect As someone who is temporarily living abroad for at least three from the beginning of the next insurance year. PRQWKV , FRQ¿UP EHLQJ HOLJLEOH IRU LQVXUDQFH RU WKDW , ZLOO EH eligible on the start date of the insurance cover. I am aware that - Insurance year family members / my non-marital partner can only be co-insured The 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- clusions Previous insurance If surcharges were payable for substandard risk prior to You need to provide Globality S.A. with your previous health conversion of the insurance, these surcharges shall also be insurance or state healthcare system details of the past 5 years levied 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 from EHQH¿WV DSSOLFDEOH LQ WKH SDVW ZLOO FRQWLQXH WR DSSO DIWHU conversion of an insurance.08/12
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