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.