A. SUBSCRIBER

    As a subscriber to the Plan, you are the legal representative towards Golden Care of all persons to insure included on this application form.
    A subscriber may choose not to be insured if cover is required for dependant(s) only.

    1. You, Subscriber

    Title*

    Situation*

    Gender*

    Date of birth (dd/mm/yyyy)*

    Country of birth*

    2. Your postal address

    3. Your contact numbers

    (please specify the country and area codes)

    4. Preferred language of correspondence

    B. COVERAGE

    1. Choose your Plan and deductible (in CHF)

    2. Specify the effective date desired (dd/mm/yyyy)

    (at earliest at noon, the day following the receipt of your application)

    3. Additional information

    Do you currently have a health insurance coverage?

    Have you been refused by another insurer for similar guarantees?

    C. PERSONS TO BE INSURED

    1. Fill out the section below, after reading the following specifications :

    • Area 1: Worldwide limited to 30 days per year in the United States and Canada

    • Area 2: Worldwide

    • If you wish to insure more than 4 children, please provide the same information as below on a separate sheet

    • If your child is between 21 and 24 years old and a full-time student, he/she benefits from the 0 to 20 year-old premium rate. lease attach proof of student status.

    • A child aged between 0 and 20 years old applying alone will be charged the 21 to 24 year-old rate. If several children apply together, the oldest will
      be charged the adult rate.

    Subscriber: Do you want to be insured ?

    If yes, select your area of coverage

    Premium (CHF)

    Spouse

    Surname

    First name

    Gender

    Nationality

    Date of birth (dd/mm/yyyy)

    Area of coverage

    Premium (CHF)

    Child 1

    Surname

    First name

    Gender

    Nationality

    Date of birth (dd/mm/yyyy)

    Area of coverage

    Premium (CHF)

    Child 2

    Surname

    First name

    Gender

    Nationality

    Date of birth (dd/mm/yyyy)

    Area of coverage

    Premium (CHF)

    Child 3

    Surname

    First name

    Gender

    Nationality

    Date of birth (dd/mm/yyyy)

    Area of coverage

    Premium (CHF)

    Child 4

    Surname

    First name

    Gender

    Nationality

    Date of birth (dd/mm/yyyy)

    Area of coverage

    Premium (CHF)

    D. PREMIUM

    1. Please select the frequency of your premium:

    E. HEALTH QUESTIONNAIRE

    This health questionnaire is not required if you have applied for the AcciCover Plan.
    If you wish to insure more than 4 children, please provide the same information on a separate sheet
    If you answer «yes» to any of the following questions, Golden Care Services requires that you mention the specifications asked for in the medical declaration joined. This information is compulsory for the assessment of your application.

    General informations

    Subscriber

    Spouse

    Child 1

    Child 2

    Child 3

    Child 4

    Surname

    First name

    Weight (kg)

    Height (cm)

    Blood pressure normal? If not, what is your blood pressure?







    Occupation (if applicable)

    What is your daily consumption of tobacco?

    What is your daily consumption of alcohol?

    Has your weight varied in the last 12 months? If yes, by how much and why?







    Has any applicant ever been denied medical or dental insurance, or offered coverage with an exclusion?

    Medical history

    Subscriber

    Spouse

    Child 1

    Child 2

    Child 3

    Child 4

    Within the last 3 years have you consulted with a physician or received medical treatment other than a routine check-up which has been completely clear?

    Have you ever been admitted to any hospital?

    Have you ever been admitted to any nursing home?

    Have you ever been admitted to any special clinic?

    Have you been informed of abnormalities in laboratory tests performed in the last 3 years?

    For women: Have you ever had any complications of pregnancy or childbirth?

    Current condition

    Subscriber

    Spouse

    Child 1

    Child 2

    Child 3

    Child 4

    Are you currently under medical supervision or taking prescribed medications for any condition?

    Do you have a birth defect or congenital abnormality or do you suffer from a chronic disease?

    Future treatment / Investigations

    Subscriber

    Spouse

    Child 1

    Child 2

    Child 3

    Child 4

    Are any medical or surgical procedures recommended, scheduled and/or contemplated?

    Is there any oral /dental condition needing treatment (other than normal cleaning & routine examinations)?

    Attending physician

    ESTABLISHMENT OF THE BENEFICIAL OWNER’S IDENTITY

    The undersigned hereby declares: (mark with a cross where appropriate):

    Statement: I hereby apply to be enrolled in the Golden Care Plan together with the persons on the present form. I declare in the name of these persons :

    • I understand the above answers are confidential and shall be used for the underwriting procedure of my application by Golden Care Services ;

    • The above questions are accurately represented and are, to the best of my knowledge and belief, full, complete and true, and that I do not have any knowledge of any circumstance that would affect the result of the evaluation by Golden Care Services related to my application for insurance;

    • I understand any false or inaccurate declaration shall be considered retroactively as a waiver of benefits and shall lead to the immediate cancellation of the Plan;

    • I am aware the Plan shall be effective at the date mentioned on each Insured’s certificate of insurance, and that the present form together with my/our medical declaration, certificate of insurance and general conditions of the Plan n°GCCH008EN or GCCHEX005EN, Underwritten by Global Health and Accident Insurance Limited which is regulated by Guernsey Financial Services Commission (licence number : 2291879). The general conditions form the basis of the contract between the insurer and the insured person(s);

    • I am aware Golden Care Services may require medical reports or a medical examination at my expense before assessment of my application;

    • I authorise Golden Care Services to obtain from doctors, insurers and other service providers, and to pass on to the same, information, including personal data, necessary for the evaluation of the insurance risk and for the management of the contract thereof;

    • I understand that refusal to submit medical information by any Insured or physician, clinic, hospital, or institution shall be considered a waiver of benefits by such Insured and the insurer shall have no further obligations towards such persons ;

    • I have read and fully understood the summary of the principal exclusions, and specifically those related to pre-existing conditions ;

    • I understand that I must notify Golden Care Services of any change in health or of any change to the information provided which takes place between the time this form is completed and the time coverage becomes effective, and that failure to do so may result in the rejection of a claim or my insurance coverage being void.

    Signature

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