BRONZE

Pre-existing Conditions – We do not cover treatment of any medical conditions (or specified condition) that existed before the start of your policy.

• Use this form to apply for our Bronze Global Prima Medical Insurance plan. ou must take care in answering all the following questions which are relevant to us in providing this insurance and setting the terms and premium. Please contact us if you do not understand the question or the nature of the information required or please seek guidance from your broker. Failure to provide information or the provision of incomplete or inaccurate information may result in the loss of cover or other remedies. Remember to sign the Declaration on page 7.
• Please write clearly using capital letters.
• If you have any questions, call us on +44 (0) 1903 817970 (UK
• If you would like a copy of this application form, please let us know within 3 months.
• We will write to you with your terms and requesting payment within 5 working days.
• Then, once we’ve received your payment, we’ll send your policy documentation.

1. Choosing your level of cover

Please tick the boxes to choose your level of cover for the Bronze plan

2. Your Details

Policy holder details

Additional family member details

Please give details of any additional family members to be covered by this policy. This includes your spouse/partner and any children under the age of 25 years of age who are permanently living with you or in full time education. If more than four additional family members are to be covered, please email their details to contact@brokerfish.com.

Please answer for each person applying for cover

Please note if a person has answered YES to any question above, he or she does not qualify for this insurance.

3. General Data Protection Regulation (GDPR)

This is only a summary of ALC’s privacy policy and your rights under GDPR. For a complete explanation of how we gather and use your personal information and your corresponding rights, please review our complete Privacy Policy, which is available at https://www.alchealth.com/privacy.htm

ALC collects many kinds of information in order to operate effectively and provide you the best products, services and experiences we can. Regardless of the source, we believe it is important to treat that information with care and to help you maintain your privacy.

When you provide data processing consent, we will process your personal information in order to provide the services you have purchased, including to administer claims, and to receive member communications, in accordance with our Privacy Policy. If you provide marketing consent, we will send you relevant information and future marketing materials regarding products or services in which you may have interest, and for all other purposes set forth in our Privacy Policy. You may withdraw your consent at any time.

By providing marketing consent, we may gather information about you from third parties to help us identify insurance products and services in which you may have interest, and share information with third parties, such as web analytics tools, in order to send you relevant information and future marketing materials, and for all other purposes set forth in our Privacy Policy. You may withdraw your consent at any time.

We may share your information with third parties who provide services on our behalf to help with our business activities. These companies are authorized to use your personal information only as necessary to provide these services to us. When we share information with these other companies to provide services for us, they are not allowed to use it for any other purpose and must keep it confidential. These services may include:

• Adjudicating and managing the claims process
• Payment processing to healthcare providers
• Providing customer service In certain situations, ALC may be required to disclose personal data in response to lawful requests by public authorities, including to meet national security or law enforcement requirements.

4. Fair Processing Notice

This Privacy Notice describes how SiriusPoint International Insurance Corporation (publ) (for the purpose of this notice “we”, “us” or the “Insurer”) collect and use the personal information of insureds, claimants and other parties (for the purpose of this notice “you”) when we are providing our insurance and reinsurance services.

The information provided to the Insurer, together with medical and any other information obtained from you or from other parties about you in connection with this policy, will be used by the Insurer for the purposes of determining your application, the operation of insurance (which includes the process of underwriting, administration, claims management, analytics relevant to insurance, rehabilitation and customer concerns handling) and fraud prevention and detection. We may be required by law to collect certain personal information about you, or as a consequence of any contractual relationship we have with you. Failure to provide this information may prevent or delay the fulfilment of these obligations.

Information will be shared by the Insurer for these purposes with group companies and third party insurers, reinsurers, insurance intermediaries and service providers. Such parties may become data controllers in respect of your personal information.

Because we operate as part of a global business, we may transfer your personal information outside the European Economic Area for these purposes.

You have certain rights regarding your personal information, subject to local law. These include the rights to request access, rectification, erasure, restriction, objection and receipt of your personal information in a usable electronic format and to transmit it to a third party (right to portability).

If you have questions or concerns regarding the way in which your personal information has been used, please contact: DPOLondon@siriuspt.com

We are committed to working with you to obtain a fair resolution of any complaint or concern about privacy. If, however, you believe that we have not been able to assist with your complaint or concern, you have the right to make a complaint to the UK Information Commissioner’s Office.

For more information about how we process your personal information, please see our full privacy notice at: https://www.siriuspt.com/legal/website-privacy- policy-final.pdf

If you do not wish the language to be English, please contact your broker or telephone us on +44 (0) 1903 817970.

Please tick if you have a local health insurance policy. You can use the eligible claims you make on your local health insurance policy to use up the excess on your ALC Health policy.

ALC Global Health Insurancewe’re different because we care

10 Your Declaration

1. I have received and read the full Definitions, Benefits, Exclusions and Condition of this Policy including General Exclusion 62 relating to Pre-existing Conditions and General Condition 8 relating to Governing Law. I understand that the Application Form, Certificate of Insurance or Declaration of Insurance (if outside the EEA or UK) and the Policy Wording make up the contract between us and all form part of the policy. I am aware that cover shall be provided in accordance with the policy.

2. I/we declare that the information disclosed in this proposal is, to the best of my/our knowledge and belief, both accurate and complete. I/we have taken care not to make any misrepresentation in the disclosure of this information and understand that all information provided is relevant to the acceptance and assessment of this insurance, the terms on which it is accepted and the premium charged.

3. I understand that if I am not satisfied with the content of this policy, I may cancel the insurance within 14 days of the completion of this contract as set out in the Policy Wording.

4. If I have indicated that I wish to pay by credit/debit card, I authorise à la carte healthcare limited to debit my account up to 4 days in advance of the collection/renewal date with the appropriate premium, and all subsequent renewal premiums due as notified until I give written notice that I wish to terminate this Agreement. I understand that à la carte healthcare limited cannot be liable if my policy is lapsed should the credit/debit card be declined and I do not respond to requests for alternative methods of payment within 7 days.

5. By signing this form as the policyholder, I confirm that:

• anyone included on the plan has agreed that the policyholder has their permission to act for them to set up this plan.

• the policyholder consents on behalf of those family members and themselves to ALC Health, its underwriters and its claims handlers using personal information in the ways described above.

• If applying for coverage with a country of residence outside of the EEA and UK or at any time move to a location outside the EEA or UK, the policyholder acknowledges and agrees to elect the Trust: the policyholder hereby applies and subscribes, for and on behalf of each individual enrolled, to the Conyers Trust Company (Bermuda) Limited, Richmond House, 12 Par-la-Ville Road Hamilton HM 08, Bermuda, or its successors, for the insurance coverage requested above and as underwritten and offered by Sirius International Insurance Corporation on the date of its receipt hereof, and as administered by ALC Health.

6. If you are arranging this insurance via a broker the policyholder understands, acknowledges and agrees that ALC Health will pay commission to the broker at inception and renewal.

7. I have read the General Data Protection Regulation (GDPR) notice as contained in this Application Form and the Privacy Policy which is available at https://www.alchealth.com/privacy.htm

8. If you don’t take reasonable care and the information you give us is inaccurate or incomplete then we may take one or more of the following actions:

(i) Cancel your plan;

(ii) Declare your membership void (treating your plan as if it had never existed)

(iii) Change the terms of your plan; or

(iv) Refuse to deal with all or part of any claim or reduce the amount of any claims payments.

We may ask you to provide further information and/or documentation to make sure that the information you gave us when taking out, making changes to or renewing your plan was accurate and complete.

No cover is in force until this proposal is accepted by the insurer and the premium is paid. The insurer reserves the right to decline any insurance proposal or to offer different premium and terms from those quoted dependent on the information you have provided.

Consent:

ALC Health and alc health are trading styles of à la carte healthcare ltd. Registered in England no 4163178. Registered Office: 254 Upper Shoreham Road, Shoreham by Sea, West Sussex, BN43 6BF, United Kingdom. à la carte healthcare ltd is authorised and regulated by the Financial Conduct Authority (FCA No 311496 London Global S.r.l. trading as à la carte healthcare. Trading address 3rd Floor, Fitzalan House, Fitzalan Court, Cardiff, CF24 0EL, United Kingdom. London Global S.r.l. trading as à la carte healthcare authorised and regulated by IVASS, Italy (A000620496) and the Financial Conduct Authority (849073 CM0050A2021230302 à la carte healthcare ltd is part of the IMG Group of Companies.

ALC Global Health Insurancewe’re different because we care