Global Health Employee Application Form Moratorium)

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EMPLOYEE APPLICATION FORM (MORATORIUM) Please complete this form in block capitals using black ink SECTION 1: TO BE COMPLETED BY THE EMPLOYER Employer: Employee name: Mr/Dr/Mrs/Ms/Miss Group No: Date of employment: GLOBAL HEALTH PLAN REQUIRED Please complete this section if the employee named above requires different cover to that stated on your Corporate Application Form. Global Health Essential Essential Care Global Health Elite Bronze Silver Gold Platinum Bespoke (50+ employees) Area of cov
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  Please complete this form in block capitals using black ink EMPLOYEE APPLICATION FORM (MORATORIUM) SECTION 1: TO BE COMPLETED BY THE EMPLOYER Employer: Group No:Employee name: Mr/Dr/Mrs/Ms/Miss Date of employment:   GLOBAL HEALTH PLAN REQUIRED Please complete this section if the employee named above requires different cover to that stated on your Corporate Application Form.Global Health Essential   Essential Care   Essential Care PlusGlobal Health Elite   Bronze   Silver   Gold   Platinum   Bespoke (50+ employees)Area of cover required for Global Health Elite plan: Standard – Area 1 World-wide cover excluding the USA.  World-wide – Area 2 World-wide with cover in the USA limited to temporary trips of up to 45 days and a benet limit of US $100,000.  World-wide Plus – Area 3 World-wide with cover in the USA limited to temporary trips of up to 90 days and a benet limit of US $250,000.  Semi-private room discount : Only available to residents of Hong Kong and Singapore.  Direct billing in Hong Kong and China: Available to residents of Hong Kong with a nil excess. Available to residents of China with a nilor $50 / £30 / € 45 excess. A 7.5% premium surcharge will apply in China. Required excess The standard excess is Nil for Essential Care and Bronze, and $50/£30/ € 45 for Essential Care Plus, Silver, Gold and Platinum ($15 / AED 55 in UAE). Nil   $50/£30/ € 45 ($15 / AED 55 in UAE per consultation) n/a for Essential Care or Bronze  $100/£60/ € 90 ($30 / AED 110 in UAE per consultation) (n/a for Essential plans or Bronze) Other, please state :   OPTIONAL GLOBAL TRAVEL PLAN REQUIREMENTS   Employee Employee and partner Employee, partner and dependants   OPTIONAL GLOBAL PERSONAL ACCIDENT PLAN REQUIREMENTS   Employee Employee and partner Exclusions apply in respect of hazardous occupations and hazardous sports. When Personal Accident Benet cover is required for an employee whoseoccupation is not 100% ofce based, or who participates in hazardous activities of any kind, a detailed job description and / or details of their hazardousactivities must be submitted to us. Cover for hazardous occupations / activities may be subject to a premium loading.   SECTION 2: TO BE COMPLETED BY THE EMPLOYEE PERSONAL DETAILS Have you previously been insured, or are you currently insured, with William Russell? Yes NoPrevious/current policy number: Date of expiry of previous policy:Have you previously been insured, or are you currently insured, with another health insurer?Yes NoName of Insurer: Your rst name: Surname: Mr/Dr/Mrs/Ms/MissAddress:Telephone No (for correspondence): Telephone No (other): Fax No:Email (home): Email (other): Date of birth: Nationality: Male FemaleCountry of residence: Occupation:Do you and/or your partner participate in any hazardous activities? Yes   NoIf YES, please give full details  FAMILY MEMBERS TO BE INCLUDED IN THE PLAN Please enter the names and details of all dependants for whom cover is required. You may include your partner and children, up to age 18 or up to age 25if in full-time education – proof will be required. Children aged 18 or over who are not in full-time education must make their own application for cover. E   GENERAL DECLARATION OF GOOD HEALTH 1. Your height (cms): Your weight (kgs): Your partner’s height (cms): Your partner’s weight (kgs):2. Have any persons named in this application ever: A. Suffered from, been diagnosed with, treated or prescribed drugs for any form of cancer, or heart disease, or any other serious or chronic illnessthat requires regular medication and/or monitoring? Yes   No B. Been tested HIV and/or Hepatitis C positive? Yes   No C. Had an application for insurance turned down or accepted at special terms? Yes   No If you answered YES to any question, please state the names(s) of the person(s) and details:   PRE-EXISTING MEDICAL CONDITIONS AND RELATED CONDITIONS The Global Health plans do not cover the treatment of pre-existing medical conditions and related conditions. A pre-existing medical conditionmeans any disease, illness or injury for which you have received medication, advice or treatment, or for which you have experienced symptoms,whether the condition has been diagnosed or not, during the 24 month period preceding the commencement of your Global Health plan.After two years of continuous cover, some pre-existing medical conditions will become eligible for benet, subject to the terms and conditionsof your plan, provided you have not consulted any doctor or medical practitioner for medical treatment or advice (including check-ups), or takenmedication, (including injections), or been advised to follow a special diet, or suffered symptoms for that medical condition, or for any relatedcondition, for a continuous period of two years.Examples of pre-existing conditions that will never be covered include diabetes, hypertension (raised blood pressure), hyperlipideamia (raisedcholesterol levels), ischemic heart disease, cancer, thyroid disease, and auto-immune disorders. If you have 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 that condition – and any relatedconditions – will never be covered. Examples of related conditions are raised cholesterol levels and heart disease and stroke. If you have sufferedfrom high cholesterol before your date of entry to the plan you will never be covered for cardiac problems or strokes.   DOCTOR’S CONTACT DETAILS 1. Please give details of the doctor who is most familiar with your medical history and the medical history of your family members. Name: Practice name:Address:Telephone No: Fax No: Email:Length of time you have known this doctor: If less than two years, please complete question 3. 2. If this doctor does not treat all persons named in this application, please supply additional information. Name: Practice name:Address:Telephone No: Fax No: Email:Who does this doctor treat? Length of time the patient has known this doctor: 3. If you or your family member(s) have known the doctor(s) above for less than two years, please provide details of the previous doctor(s). Name: Practice name:Address:Telephone No: Fax No: Email:Who did this doctor treat? Length of time the patient has known this doctor:Date of last consultation:First name(s)SurnameDate of birthdd/mm/yyRelationship toapplicantCountry of residenceOccupation/Full-time educationPartnerChild Yes   No Child Yes   No Child Yes   No Child Yes   No Please continue on a separate sheet if necessary.  THE INSURER If you are resident in the United Arab Emirates (UAE), the insurer of your Global Health plan will be Dubai Insurance Company psc.If you a resident outside the UAE, the insurer of your Global Health plan will be Hauteville Insurance Company Limited. DECLARATION AND AUTHORISATION I hereby apply for cover on behalf of all the persons named in this application form under my employer’s Global Health plan as speciedabove. I declare that all the persons named in this application form are in good health, and not aware of any symptoms or pre-existingmedical conditions that may give rise to a claim under the Global Health plan.I declare that I have read and understood the plan agreement of the Global Health plan as specied above and that I am aware that covershall be provided in accordance with the agreement. I fully understand that pre-existing conditions as dened in the Global Health planagreement shall not be covered by the insurance plan. I authorise any doctor who has ever treated or advised any of the persons named inthis application to provide William Russell Limited with any information they may require in connection with treatment related to any claimunder this plan. I declare that the information given in this application is true and complete.If my employer has applied for a travel insurance plan, I declare that at the time of purchasing this insurance or at the time of booking anyfuture trip(s), I am aware of no reason why any journey or trip should be cancelled or curtailed or expense be incurred.Signature of employee: Date: Signed on behalf of the employer: Date: Position in Company:IMPORTANT: Please ensure you have given an answer to every question. An incomplete form will delay your application. EMP/GHMOR/09/v1 www.william-russell.com William Russell Limited William Russell House,The Square, Lightwater,Surrey, GU18 5SS, UK. T + 44 1276 486455 F + 44 1276 486466sales@william-russell.com William Russell (Asia Pacic) Limited Marketing Ofce, Suite 7-3, 7th Floor,Wisma UOA II, 21 Jalan Pinang,50450 Kuala Lumpur, Malaysia. T + 6 03 2171 2071 F + 6 03 2171 2072klofce@william-russell.com Dubai Insurance Company PO Box 3027, Dubai, UAE. T + 971 4 2693030 (Ext 102) F + 971 4 2693727sales@globalplans.aewww.globalplans.ae
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