OPTIMUM GLOBAL - APPLICATION FORM

APPLICATION FORM

Full Medical Underwriting
Please complete this form in block capitals. Payment must be submitted before any cover can be granted. You must disclose in this form, fully and faithfully, all material facts. A material fact is one that is likely to affect the assessment of this health insurance application. Failure to do so may result in you not receiving any benefit from your policy.

This form consist of 4 Sections, please ensure to complete all information.

First Section: Your Choice of Medical Cover and payment details. Part of this information may be pre-filled if you have obtained a quote from us.

Second Section: Policy Holder and Dependent Details. Name, address, etc.

Third Section: Disclosure of Medical Details. Here you give details about your medical history.

Fourth Section: Declaration and Signature.
Are you a member of any Society or Association?*

YesNo
Network member of*
Please select the name of your Society or Association
Please attach proof of your membership in the Society or Association. This can be a membership card or an email confirmation from the organization.

If you do not have proof of membership readily available, please organize this and send to: contact@brokerfish.com
Cancelof

Your Choice of Medical Cover and Payment Details
Optional Dental, Optical and/or Maternity is only available on Ruby, Jade and Diamond
Core Plan:*

Plan 1: EmeraldPlan 2: SapphirePlan 3: RubyPlan 4: JadePlan 5: Diamond
Do you wish to purchase any of the options: 1. DENTAL 2. OPTICAL or 3. MATERNITY benefits (Not available on Emerald or Sapphire)*

YesNo
Dental, Optical and Maternity premiums are per person per year. Same premiums for all ages.

Maternity rates only applies to the female who should enjoy maternity coverage (waiting periods apply before benefits are payable).

Do you wish to add dental cover?*

YesNo
Leave blank if all family members should have dental, else specify the name(s) for those who want dental.

Do you wish to add optical cover?*

YesNo
Leave blank if all family members should have Optical, else specify the name(s) for those who want optical benefits.

Do you wish to add maternity cover?*

YesNo
Which female family members wish to benefit from the optional maternity cover
Please note that remaining family members must choose the same Core Plan as those members opting for maternity cover.
Area of Cover:*

Option 1: Worldwide including USAOption 2: Worldwide excluding USAOption 3: Asia (Bangladesh - Bhutan - Brunei - Cambodia - East Timor - India - Indonesia - Japan - Laos - Malaysia - Maldives - Mongolia - Myanmar - Nepal - Pakistan - Philippines - Sri Lanka - Taiwan - Thailand - Vietnam)Option 4: Africa (including India & Pakistan)
Policy Currency (Please select):*

USDEURGBP
Outpatient Co-Pay option please select:*

Option 1: Nil co-paymentOption 2: 10% co-paymentOption 3: 20% co-payment
Inpatient Deductible option please select:*

Option 1: NilOption 2: USD $500 / EUR €400 / GBP £300Option 3: USD $1,000 / EUR €800 / GBP £600Option 4: USD $2,000 / EUR €1,600 / GBP £1,200Option 5: USD $5,000 / EUR €4,000 / GBP £3,000Option 6: USD $10,000 / EUR €8,000 / GBP £6,000
Do you wish to add optional Life Cover? (please note, this option is only available to members aged 18-64 yrs)*

YesNo
Resident Country
Sum Assured

Unfortunately your current resident cuntry is not eligable for Life cover.
Do you wish to add USD/EUR/GBP 50,000 of life cover with rates as above?

YesNo
Please enter the names of individuals to be covered by the life insurance
Do you wish to add USD/EUR/GBP 100,000 of life cover with rates as above?

YesNo
Please enter the names of individuals to be covered by the life insurance
LIFE INSURANCE BENEFICIARY DESIGNATION

Important notes:
• Only complete this form if you have purchased the optional Life benefit option
• If more than one person is purchasing the Life cover option, please complete one beneficiary designation form per person
• Use this form to name the persons or entities you want to receive your life insurance proceeds after your death.

1. Primary Beneficiaries
These parties are your first choice to receive the insurance proceeds after your death. If a primary beneficiary dies before you, we will divide their share(s) equally between the remaining primary beneficiaries. You must name at least one (1) primary beneficiary. Please complete the form fields below for each beneficiary you name. Having accurate information for your beneficiaries ensures that we distribute the proceeds the way you want. Use the proceeds % field to tell us how you want us to distribute the proceeds. If you want a specific distribution, use whole numbers (no fractions or decimals) and make sure they add up to 100%.

Please note, should all beneficiaries predecease the person covered, we will pay the life benefit to the estate of the deceased.

Insured’s Printed Name
Date

DayMonthYear
Insured’s Signature

Clear
5. METHOD OF PAYMENT AND CONTRACT DETAILS
Date you want cover to commence*

DayMonthYear
(Please note this date cannot be prior to the date we receive this application form)
Premium payment options:*

AnnualSemi-Annual (3% Loading)Quarterly (5% Loading)
*Any charges made by the remitting bank and receiving bank in the course of submitting funds to Optimum Global Limited must be borne by the applicants. This may mean that it is necessary to pay an amount in excess of the contribution due to the plan to cover these charges.

Please indicate your name and invoice number when remitting payment. Please remit the amount to the currency denominated bank account of Optimum Global Limited as shown on your invoice.

Disclosure of Medical Details
6. CONFIDENTIAL MEDICAL HISTORY

Smoker?*

	Yes	No
Main applicant
Spouse / Partner
Child 1
Child 2
Child 3

1. Has any person named in this form been admitted to a hospital or nursing home or had any medical tests done in the last 4 years?*

	Yes	No
Main applicant
Spouse / Partner
Child 1
Child 2
Child 3

2. Has any specialist been consulted and/or provided prescriptions for any drugs or medication in the last 4 years?*

	Yes	No
Main applicant
Spouse / Partner
Child 1
Child 2
Child 3

3. Has any application for life, accident, health or any other insurance been refused or had special terms applied?*

	Yes	No
Main applicant
Spouse / Partner
Child 1
Child 2
Child 3

4. Does any person named in this form anticipate the need or has been recommended to undergo any medical tests or investigations in the foreseeable future?*

	Yes	No
Main applicant
Spouse / Partner
Child 1
Child 2
Child 3

5. Has any person named in this form ever suffered from or are suffering from any disease or condition stated below? Please tick box if ‘Yes’

Heart trouble or chest painsBlood pressure problems or circulatory disordersFainting, blackouts, dizziness, seizures, fitsStrokes or paralysisAsthma, persistent cough, breathlessness or other respiratory disordersStomach ulcer, liver, hepatitis, gall bladder, intestinal or bowel disordersKidney, bladder, prostate or genito-urinary disordersGynaecological or hormone disorders or irregularityDiabetes, cholesterol problems or diseases or disorders of the bloodTumour, growth, cancer or glandular diseases or abnormalitiesDiseases or disorders of the eyes, ears, nose or throatDiseases or disorders of the back, bones, joints, muscles or skinMental or nervous disordersAIDS, HIV or venereal diseasesAny diseases, disorders or conditions which are long lasting or recurrentTreatment for drug or alcohol addiction or abuseAny other illnesses, disabilities or defects present that may require treatment that have not already been disclosed
If you have answered ‘yes’ to any of the above questions, please complete the additional supplementary medical questionnaire, providing more details by indicating the question number, the condition, dates of consultation, the treatment received and the name and address of doctor. Please attach a copy of all medical reports if applicable. Attach these items to this form and indicate you have done so by ticking this box:*

I answered 'yes' or 'ticked a box' and will provide the Supplementary Medical QuestionnaireAll answers 'no' or 'blank'
Supplementary Medical Questionnaire

The Questionnarie opens in a new window and the link is also avaliable on the "Thank You" page after you have submittet this form.

Please ensure to submit a form for each condition of each applicatant so your and your dependents medical history is fully declared.

Declaration and Signature
7. Declaration

Benefits may not be payable if you do not fully disclose any material facts requested within this application form and any supplementary medical questionnaires which you may be required to complete as part of the application process. Material facts are those which could influence our assessment and acceptance of this application and, if you are in any doubt as to whether any facts are material, you should disclose them.

Personal Data provided in this application form will be used and processed by us in line with our Privacy Policy which can be found on our website, or which can be requested from us at any time.

I hereby give my consent to Optimum Global Limited or any agent thereof to process the data supplied in this application form for the purposes of insurance intermediation, selection and/or compliance. I accept that this data may be sent and processed outside the UK in a country without specific data protection laws (this only applies if you have lived or worked overseas.

I/We declare that all the information on this application form is true and complete. I am/We are unaware of the existence of any medical condition or circumstance foreseeably requiring my/our hospitalisation in the future, and understand that benefits will not apply to treatment or expense arising from medical conditions which originated or were known to exist or for which treatment, medication, advice or diagnosis was sought or received prior to my/our enrolment in the Policy unless such conditions are fully disclosed to and accepted by Optimum Global Limited prior to the inception of the Policy. I/We consent to Optimum Global Limited seeking information from any doctor who has attended to me/us and I/we authorise the giving of such information. I/We further authorise Optimum Global Limited to give such information obtained or information contained herein for the purpose of obtaining insurance cover under this application to my insurance representative. I/We understand that Optimum Global Limited may require further medical information from my doctor and I/we am/are aware that I am/we are responsible for obtaining and paying for such information should I/we wish to continue my/our application. I am/We are aware that I/we can seek advice from a qualified adviser before I/we sign this application form. Should I/we choose not to, I/we take sole responsibility to ensure that this product is appropriate to my/our financial needs and insurance objectives. I/We have received Optimum Global Policy Conditions and the product benefit table and they have been explained to my/our satisfaction.

I/We agree that any cover which I/we may purchase for the USA shall terminate upon informing Optimum Global Limited that I/we have become a resident of the USA. I/We agree that this application shall be the basis of the contract of insurance between me/us and Optimum Global Limited. I/We understand that the insurance shall not become effective until it is accepted and confirmed in writing by Optimum Global Limited.
Signature of Main Applicant*

Clear
Date*

DayMonthYear
Signature of Spouse/Partner

Clear
Date

DayMonthYear

END
Broker / Agent*
Please verify that you are human*
Should be Empty:

	RUBY	JADE	DIAMOND
DENTAL	USD 873 GBP 590 Euro 698	USD 873 GBP 590 Euro 698	USD 1,091 GBP 738 Euro 873

	RUBY	JADE	DIAMOND
OPTICAL	USD 138 GBP 93 Euro 110	USD 173 GBP 117 Euro 138	USD 206 GBP 139 Euro 165

	RUBY	JADE	DIAMOND
MATERNITY (per female)*	USD 2,672 GBP 1,806 Euro 2,138	USD 2,672 GBP 1,806 Euro 2,138	USD 2,980 GBP 2,014 Euro 2,384

Age Band	Annual Premium (USD/EUR/GBP)
18-24	34
25-29	52
30-34	72
35-39	81
40-44	122
45-49	172
50-54	304
55-59	411
60-64	631

Age Band	Annual Premium (USD/EUR/GBP)
18-24	68
25-29	103
30-34	143
35-39	161
40-44	244
45-49	343
50-54	607
55-59	822
60-64	1,263

	Name	Address	Relationship to the Covered Person	% of Death Benefit Payable to Beneficiary (must total 100%)
Beneficiary 1
Beneficiary 2
Beneficiary 3
Beneficiary 4