HCI Protector - Application Form

Application Form

FMU / CPME / MORATORIUM UNDERWRITING
About you
Title
Which country will you be living in?*
Name*

Your first nameYour surname
Your address*
Postcode - Zip Code*
Date of birth*

DayMonthYear
What’s your nationality?*
Where were you born?*
YES – please give detailsNO
Your other/alternative address
Postcode - Zip Code
MaleFenale
MARRIEDDIVORCEDSINGLEOTHER – please give details
What’s your height?*
CMFT
What’s your weight?*
KGLB
BY EMAILBY AIRMAIL (standard)BY COURIER (£40/€75/$75 charge)
What’s your occupation?*
Which address should we send your policy documents to?
YESNO
YES - please give detailsNO
Details of manual labour
Your email*
example@example.com
Your phone number (including country code)*

Country CodeArea CodePhone Number
YES– please give details including ID numbersNO
Details of Social Security or government plan or any other medical insurance plan
YES – please answer the questions belowNO
If you answered no above, you can go straight to ‘Build your plan’
_____________________________________

Your Partner (if applicable)
First name
Surname
MALEFEMALE
Height?
CMFT
Weight?
KGLB
Date of Birth

DayMonthYear
Occupation?
Nationality?
YES– please give details including ID numbersNO
Details of any Social Security or government plan or any other medical insurance?
Birthplace
_____________________________________
Your Children (if applicable)

For children over 21, please send us proof of their schooling.

Rows	Name	Nationality	Date of birth	Gender	Height	Weight	Full-time student?
Child 1
Child 2
Child 3
Child 4

YES– please give details including ID numbersNO
Give details for any children eligible for benefits from any Social Security or government plan or any other medical insurance?
Build your plan

Which plan suits your needs best?
Emergency + plan with excess of £/€/$ 0Emergency + plan with excess of £170 / €210 / $250Emergency + plan with excess of £710 / €860 / $1,000Emergency + plan with excess of £1,400 / €1,700 / $2,000Standard plan with excess of £170 / €210 / $250Standard plan with excess of £710 / €860 / $1,000Plus plan with excess of £170 / €210 / $250Plus plan with excess of £710 / €860 / $1,000Premium plan with excess of £/€/$ 0Premium plan with excess of £170 / €210 / $250Premium plan with excess of £710 / €860 / $1,000Executive plan with excess of £/€/$ 0Executive plan with excess of £170 / €210 / $250Executive plan with excess of £710 / €860 / $1,000
Add dental coverage
Personal Accident

Rest easy knowing your loved ones aged 18 or over are looked after if the worst was to happen with a lump sum payment up to £17,800/€21,700/$25,000.

You can increase this in increments of £/€/$10,000 to a maximum of £87,800/€101,700/$125,000. This must be in the same currency as your plan and applies only to members aged 18 or over.

Note that the premium payable for this coverage has not been included in any quotes presented on the BrokerFish.com site unless specifically stated so.

Please show the amount of cover required for policyholder and spouse/partner:
Policyholder
Spouse/partner
How much would you like to set your co-pay as? Co-pay means the amount You have choose to contribute towards costs following an Insured Event, over and above Your chosen Deductible, and which is shown on Your Certificate of Insurance. The higher co-pay the lower the premium. Premiums displayed on this site is with a co-pay of nil/zero unless specifically stated and any higher % of co-pay selected here would lower your premium.*

0 %10 % - gives 5 % discount on your premium20 % - gives 10 % discount on your premium30 % - - gives 15 % discount on your premium
AREA 1: All countries worldwideAREA 2: All countries worldwide, excluding the USA and its outlying islands.AREA 3: All countries worldwide excluding: China, Greece, Guatemala, Honduras, Hong Kong, Israel, Jersey, Mexico, Russian Federation, Singapore, Spain, Switzerland, United Kingdom, USVI and United States of America.
USD ($)EUR (€)GBP (£)
When would you like the cover to start?*

DayMonthYear
HealthCare International – Health Application Form
Full Medical Underwriting - Full Medical Underwriting may be a good option for you if you’re totally free from any pre-existing medical conditions or you have some that you don’t want to be covered for. We ask you a few extra questions and depending on your answers, we can exclude certain conditions meaning you won’t be able to claim on them but this will give you a 10% discount for life. You can always ask us to review your exclusions if your health changes. Now answer all the questions below in ‘Your health’.Moratorium - If you select this option there is a 11 % loading on the presented rates. Moratorium underwriting doesn’t cover any medical conditions you’ve had in the last two years (five years for cardiac or cancer conditions) before your policy begins. But you will be covered for these conditions if you don’t experience symptoms or need treatment, consultations, advice, medication or a special diet after two years of continuous cover with us (five years for cardiac or cancer conditions). This time is known as the ‘Moratorium waiting period’. We don’t class routine check-ups as active treatment so if you’re confident that you won’t need treatment for a pre-existing condition within the next two years, Moratorium may be the right cover for you but it’s worth bearing in mind that you won’t get any premium discounts with this type of underwriting. Now answer questions 1–5 below in ‘Your health’CPME - Continued personal medical exclusions may be a suitable option if you already have a health insurance plan in place and are looking for alternative cover whilst retaining your existing level of benefits.Now answer all the questions below in ‘Your health’.
Your health

We need to know a little bit of your medical history so we can make sure your plan’s right for you.
YESNO
YESNO
YESNO
YESNO
YESNO
If you’ve chosen Moratorium cover, you can skip this section. If you’ve chosen Full Medical Underwriting or CPME, please answer the rest of the questions.

Has anyone been advised, counselled, tested, diagnosed, treated, hospitalised or recommended for treatment in the last 10 years for the following:
YESNO
YESNO
YESNO
YESNO
YESNO
YESNO
YESNO
YESNO
YESNO
YESNO
YESNO
YESNO
YESNO
YESNO
YESNO
YESNO
YESNO
YESNO
YESNO
YESNO
YESNO
YESNO
YESNO
YESNO
YESNO
YESNO
YESNO
YESNO
YESNO
YESNO
YESNO
If you’ve answered yes to any question, please give details below.

Ongoing?

Rows	Question	Person	Condition/ diagnosis	Treatment	Dates	Ongoing	Name, location and number of physician, hospital or institution
1
2
3
4

Your family doctor (if applicable)
Their name
Their email
example@example.com
Their phone number (including country code)

Country CodeArea CodePhone Number
Their address
Their fax number (including country code)
POSTCODE
How would you like to pay?
By bank transfer (annual payments only)Online payment
ONLINE PAYMENT

You can make your payment(s) Online via the insurers website by visiting this URL address: https://www.healthcareinternational.com/payment

BANK TRANSFER

Account name: HealthCare International
Bank: HSBC
Reference: Your policy number or quote reference

For Sterling (£) transfers
Sort code: 400530
Account number: 04565975
IBAN: GB29MIDL40053004565975
SWIFT/BIC: MIDLGB22

For Euro (€) transfers
Sort code: 400515
Account number: 59763197
IBAN: GB29MIDL40051559763197
SWIFT/BIC: MIDLGB22

For US Dollar ($) transfers
Sort code: 400515
Account number: 59763170
IBAN: GB79MIDL40051559763170
SWIFT/BIC: MIDLGB22
Your declaration
I understand that this policy is designed to cover expatriates and, as I live outside my normal home country, I consider myself to be eligible for the cover. I’m applying for an annual insurance policy and I agree that if I pay the premium by instalments and then cancel my plan during the policy period, I may still need to pay the remaining premium. I confirm that all the information I’ve given is true and complete to the best of my knowledge.

I understand that my plan may be cancelled or my claims denied if I don’t disclose my information. I’ve read and agree to the terms and conditions of the insurance plan and understand that I won’t be covered until my application is accepted and HCI has received my premium.

I understand that HCI will use this information to evaluate my application and any claims I may make. I understand that if I’m not happy after I’ve received a certificate of insurance and associated documents, I can cancel this application and receive a full refund of the premium I’ve paid as long as I have not submitted a claim or used the policy for a visa application. I agree to then send back these documents within 14 days. I authorise you to charge my card account unspecified amounts for my annual HCI health insurance plan as and when the premiums are due until I let you know in writing. I understand that you’ll tell me my renewal premium at least four weeks before my renewal date.

I authorise any medical professional, hospital, clinic, facility, government agency, insurance company, other person or firm to give HCI and their authorised representatives information including copies of records of advice or treatment given to me and/or my dependants. This includes information about medical and mental illness or drug or alcohol use.
Please sign below to agree to the above declaration*
Date*

MonthDayYear
Please verify that you are human*
Should be Empty:

Application Form

About you

Build your plan

Your health

How would you like to pay?

Your declaration