FIRST CARE 200 INTERNATIONAL PLAN

FIRST CARE 200 INTERNATIONAL PLAN

PACIFIC CROSS
MEDICAL INSURANCE APPLICATION
IMPORTANT:

Please complete this application in block capital letters. All information supplied will be treated in strict confidence. Please keep a record (including copies of all letters) of all information supplied to us for the purpose of entering into this contract.

Commencement date: The inception date of this policy will generally be the date on which this application is received and accepted by the Insurers. However, should you require an inception date in the future (to take account of the expiry of current contracts elsewhere) you may do so by completing the commencement date box in section 1. Under no circumstances will policies be backdated from the date of acceptance.

Insurance year is a twelve month period. Mid-Policy cancellation is not allowed regardless of the chosen payment frequency. This application is valid for 1 month from the date it has been signed.

The maximum age of enrollment : 55 years old You will not be able to buy FC200 when you reach the age of 56
1. Policyholder details (*Name as shown in your passport)
Name of Policyholder (Family/First)*
Phone Number*

Country CodeArea CodePhone Number
Address *
City*
Country*
Email*
example@example.com
Commencement date of your policy*

DayMonthYear
The inception date of this policy will generally be the date on which this application is received and accepted by the Insurers. However, should you require an inception date in the future (to take account of the expiry of current contracts elsewhere) you may do so by completing the commencement date box in section 1. Under no circumstances will policies be backdated from the date of acceptance.
2. Insured persons to be included in this plan (*Name as shown in your passport)

INSURED PERSON’S DETAILS*

	Insured Person #1	Insured Person #2	Insured Person #3	Insured Person #4
Family Name
First Name
Passport Numbers
Occupation
Duties
Heavy lifting (Yes/No)
Date of Birth (MM/DD/YYYY)
Sex (M/F)
Relationship to policy holder
Height (CM)
Weight (CM)
Country of Citizenship
Country of Residency

If there is insufficient space for inclusion of all dependants , please provide ALL details below.
MORATORIUM MEDICAL QUESTIONS
3. Medical Questionnaire
1. Suffered from, been diagnosed with, treated or prescribed drugs for, any form of cancer, or heart disease, or any other serious or chronic illness that requires regular medication and/or monitoring? chronic illness that requires regular medication and/or monitoring?
At any time prior to the application, have you ever had symptoms of or been diagnosed, investigated or treated for any of the following (outline the specific item and explain in the space provided below).
a) speech defect, paralysis, hearing loss, physical defect, infirimity, congenital illness, genetic deformity or disease or chronic condition?:b) asthma, respiratory or allergic condition or disorder of the eyes, ears, nose or throat? : c) psychiatric or mental disorder, fainting, blackout, mood change, drug/ alcohol addiction, seizure or fit?
b) asthma, respiratory or allergic condition or disorder of the eyes, ears, nose or throat?
c) psychiatric or mental disorder, fainting, blackout, mood change, drug/ alcohol addiction, seizure or fit?
d) hypertension, high/low blood pressure, chest pain, cholesterol problem, dizziness, heart or circulatory disorder?
e) kidney stone, venereal disease, or disorder of the bladder, prostate, kidney or genito-urinary tract?
f ) hepatitis, ulcer, hemorrhoid, colitis or stomach, gall bladder, liver or bowel disorder?
g) sciatica, back pain, joint pain or rheumatic, arthritic, muscle, joint or bone disease or disorder?
h) blood abnormality or blood vessel disorder?
i) HIV, AIDS, AIDS Related Complex, or any indication of blood or immune system disorder?
j) cancer, tumor or cyst?
k) skin disorder?
l) diabetes mellitus, glandular or hormonal disorder?
m) rheumatic fever, gout, malaria or hernia of any kind?
n) gynecological disorder or disease or complication associated with pregnancy?
o) are you pregnant now? (for female only)
p) any other ailment, impairment, or injury?
3. Are you currently undergoing any investigations or taking any medications or receiving any form of treatment recommended or prescribed? (list with dosage)
4. Have you been a patient in a hospital or sanitarium for surgery, observation or treatment in the last 5 years?
5. Have you ever smoked or otherwise used tobacco? (if “Yes”, please advise the consumption (pack) and duration of tobacco use)
Additional information to Medical Questionnaire

If you answered “Yes” to any of the questions above, please provide details here : the name of the person, the precise question number diagnosis, dates and duration of illness/injury/treatment and the names and addresses of attending physicians and medical facilities. Also, please provide all medical reports available, the lack of which may delay or invalidate this application.

	Person	Question No.	Details
1.
2.
3.
4.
5.

Important Information About Pre-existing Conditions

First Care 200 Plans do not cover the Treatment of Pre-existing Medical Conditions and related conditions.

A pre-existing condition means any disease, Illness or Injury for which the Insured has received medication, advice or Treatment, or which the Insured has experienced symptoms, whether the condition has been diagnosed or not, at any time before the date on which the Insured’s Plan starts.

After two years continuous membership, any pre-existing medical conditions (and related conditions) will become eligible for benefit, subject to the terms and conditions of the Insured’s plan, provided the Insured has not during that period: a) consulted any Medical Practitioner or Specialist for Treatment or advice (including check-ups); or b) experienced further symptoms; or c) taken medication or been advised to follow special Treatment (including drugs, medicine, special diets, injections, etc.

Examples of Pre-existing Conditions that will never be covered include diabetes, hypertension (raised blood pressure), hyperlipidemia (raised cholesterol level), ischemic heart disease, cancer, thyroid disease, and auto-immune disorders.

If the Insured has suffered from any of these conditions, or any other condition for which it is generally accepted medical advice that it be monitored in any way, then the condition - and any related conditions - will never be covered. Examples of related conditions are raised cholesterol levels and heart disease and stroke.

If the Insured has suffered from high cholesterol before the Insured’s date of entry to the plan the Insured will never be covered for cardiac problems of strokes.

IMPORTANT:
Please ensure you have given an answer to every question. An incomplete form will delay your application.
4. Plan and Options Available
Please Select your Plan. Currency is USD.*

INPATIENTINPATIENT + OUTPATIENT
ZONE OF COVERAGE: Pasific Cross have created a unique zone including Worldwide excl. North and South America, China, Hong Kong, Taiwan, Japan, Singapore, Israel, UAE, Russia, Switzerland, and United Kingdom
5. Premium payment
Please Select Payment Frequency*

ANNUALSEMI-ANNUAL (Subject to 2% loading)
PREMIUM DUE
Name of the Card Holder*
Relationship to Policyholder
Signature of Cardholder*

Clear
Signature of Cardholder - Until further notice (one-month advanced written notice is required to terminate this payment instruction), I authorize PACIFIC CROSS INSURANCE COMPANY LIMITED to charge the premium, including instalment payments for this insurance policy, to my credit card account.*

Clear
Date (MM/DD/YYYY)*

MonthDayYear
Date
6. Claims Reimbursement

For any bank transfer, please complete the following information.
Account Holder’s name
Account No. (IBAN for Euro zone)
Bank Currency
Full bank name and address
BIC / SWIFT bank code
Bank ID (If applicable)
NOTES

1. For adult applicants included in this application form, separate claim reimbursement account should be provided. Otherwise, an authorization form together with the proof of relationship must be submitted.

2. Please note that bank transfers take up to 72 hours once claim is processed.

3. Reimbursements by Bank Transfer are effected in full by the insurer, net of bank charges. However additional bank charges may be passed on to you by your own bank, for which you are liable.
7. Declaration by Policyholder

1. I hereby apply for cover on behalf of all the persons named in this application form.

2. I certify that the statements made by me in answering the above questions are true, complete and to the best of my knowledge and belief. I understand that nullity of the insurance or reduction of the insured capital sum might be applied if it were proved that the person to be insured had established a false declaration. I confirm that I have checked and found correct any answers or statements in this application that are not in
my own handwriting.

3. I accept that the policy will be subject to the policy terms and conditions effective at the time of commencement. I confirm that I have read and I understand the full definitions, benefits, exclusions and conditions of this policy.

4. I agree to accept and conform to the terms of the policy when issued unless I cancel this policy within 15 days from the commencement date.

5. I hereby authorize any licensed physician, medical practitioner, hospital, clinic, or other medical or medically related facility, insurance company, or other organization, institution, or person that has any records or knowledge of me or my health, to give to PACIFIC CROSS INSURANCE COMPANY LIMITED any such information. A photocopy of this authorization shall be as valid as the original.

6. I further authorize the Company to provide my personal data, including but not limited to health and details of the claims incurred, to reinsurance companies with whom the Company has or proposes to have dealings, or to any agent, contractor, or third-party service provider who provides services to the Company in connection with the operation of its business.

7. I hereby declare and agree that the Policyholder shall have the authority to deal with, receive, or request information from the Company concerning the Insured Person(s) in relation to any claims or matters arising from the policy issued pursuant to this application. I further agree that payment of any benefits hereunder to the Policyholder or Insured Person(s) in relation to all claims shall constitute a full discharge on the part of the Company in relation to such claims.

Important Note:

The policy is written in the English language and is intended for use only by persons who are able to read and understand its terms. Do not sign this application form if you do not understand the policy.
Policyholder’s signature*

Clear
Date(MM/DD/YYYY)*

MonthDayYear
E-mail: inquiry@pacificcross.com

Website: www.pacificcross.com The Third Party Administrator for Pacific Cross Insurance Co., Ltd. is International Administrators Limited: 11/F, O.T.B. Building, 160 Gloucester Road, Wanchai, Hong Kong, SAR Tel: (852) 2573-2278, (852) 2573-2535 Fax: (852) 2573-2917
HOW TO MAKE CLAIM:

In order to successfully claim, please follow our claims instructions and use the (Notification of claim) document on our website at www.pacificcross.com In case of an urgent situation where you required to be admitted into a clinic or an hospital or in case an emergency evacuation may be necessary. It’s an OBLIGATION to involve our emergency assistance company by using the phone number +852 2807 1728 For General requests : please write to us at inquiry@pacificcross.com or call us at +852 2573 2535
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FIRST CARE 200 INTERNATIONAL PLAN

MEDICAL INSURANCE APPLICATION

MORATORIUM MEDICAL QUESTIONS

3. Medical Questionnaire

HOW TO MAKE CLAIM: