PRIVATE MEDICAL INSURANCE BUSINESS HEALTHCARE AND CORPORATE HEALTHCARE

Transcription

1 MORATORIUM APPLICATION FORM PRIVATE MEDICAL INSURANCE BUSINESS HEALTHCARE AND CORPORATE HEALTHCARE For employees (new business and mid-term joiners) and addition of dependants to apply for VitalityHealth membership. To be used for plans: that commenced on or before 30 June 2015 and have a plan number beginning with 50 that renew on or before 30 June 2015 and have a plan number beginning with 20, 30, 40 or 50 Please ensure you complete all fields unless advised otherwise. Please complete this form using black ink in BLOCK CAPITALS. Please ensure that you are completing the application form which relates to the product and underwriting option selected by your employer and you have read the important information regarding eligibility in section G on page 5. The VitalityHealth plan declaration must be signed and dated by the employee. Please check all details on the application. If any details are incorrect put a line through them, write in the correct details and initial the change. A WHO IS THIS APPLICATION FOR? Please tick one box to indicate who this application form has been submitted for: New company plan employee (and dependants) Existing company plan mid-term employee joiner (and dependants) Existing employee on cover addition of dependants B EMPLOYMENT DETAILS Employer name Company plan number Date your employment commenced D D M M Y Y Y Y Date you would like cover to begin D D M M Y Y Y Y If this is a new company plan this will be the date your employer s plan is commencing with us. If you are a new employee this is likely to be the date of employment. If you are an existing employee, this is likely to be the date you become eligible to join the plan. If required, a date up to 45 days in the future, from the date you have signed and dated this application form, can be requested. PRUHF21789A_0515_ENP_BHC/CHC_EMPLOYEE_MORI VITALITY.CO.UK/HEALTH

2 C EMPLOYEE DETAILS Gender Male Female Address Postcode Please note that we cannot accept c/o the company for a member s address. A full residential address is required. Telephone number (home) Telephone number (mobile) Telephone number (work) Only leave blank if no address exists. D COVER DETAILS YOUR EMPLOYER HAS MADE SOME COVER CHOICES FOR YOU WHICH ARE BASED ON YOUR EMPLOYEE CATEGORY. PLEASE TELL US IN THE BOXES BELOW WHICH EMPLOYEE CATEGORY YOU ARE IN AND ALSO INDICATE WHICH HOSPITAL LIST APPLIES. IF YOU RE NOT SURE OF THE DETAILS, PLEASE ASK YOUR GROUP SECRETARY. Employee category Hospital list Local Countrywide Premier (Business Healthcare applicants only) E SPOUSE/PARTNER AND CHILD DEPENDANT DETAILS COMPLETE ONLY IF THERE ARE OTHER ELIGIBLE APPLICANTS TO BE COVERED BY THIS PLAN. If you have more than five dependants, please provide their details on a separate sheet of paper, sign and date it, and attach it to this form, or use the Notes section at the back. details are only required for child dependants who are aged 18 or over. SPOUSE/PARTNER/CHILD (DEPENDANT 1) Gender Male Female PAGE 2 OF 8

3 E SPOUSE/PARTNER AND CHILD DEPENDANT DETAILS (CONTINUED) CHILD (DEPENDANT 2) Gender Male Female CHILD (DEPENDANT 3) Gender Male Female CHILD (DEPENDANT 4) Gender Male Female CHILD (DEPENDANT 5) Gender Male Female Please enter below the names of any applicants who are employed in the occupations listed below (leave blank if this doesn t apply to any applicants): Working offshore in the extraction / refinery of natural / fossil fuels. Name(s) of applicant(s) Armed forces personnel (including territorial army). For details of what cover is available for these occupations, please refer to your plan terms and conditions. PAGE 3 OF 8

4 F MORATORIUM UNDERWRITING WHAT IS MORATORIUM UNDERWRITING? Under moratorium underwriting, we do not ask you to give details of your medical history. Instead, we apply a straightforward exclusion clause (our moratorium clause ) which says: We cannot pay claims for the treatment of any medical condition which you have received medical treatment for, had symptoms of, asked advice on or to the best of your knowledge and belief were aware existed in the five years before your cover start date (a pre-existing medical condition ). After two years of continuous insurance cover from the cover start date, all pre-existing medical conditions will become eligible for benefit, subject to the terms and conditions of the plan. However, this only applies if you have not: consulted anyone (e.g. a GP, dental practitioner, optician or therapist, or anyone acting in such a capacity) for medical treatment or advice (including check-ups), or; taken medication (including prescription or over-the-counter drugs, medicines, special diets or injections) for that pre-existing medical condition or any related condition for two continuous years after your cover start date. This clause can easily be broken down into three parts: Firstly, medical conditions that are covered from the first day of your insurance. These are conditions that are new to you after taking out your plan. Secondly, pre-existing medical conditions which become eligible for cover after at least two years continuous insurance. We cover them if you have stayed free from receiving any treatment, advice or medication for a continuous period of two years after your cover start date. Thirdly, pre-existing medical conditions which we permanently exclude from cover. We exclude them because you will need regular or periodic treatment, advice or medication and you will never be able to remain free of this help for any continuous two-year period. Your plan will probably never cover any pre-existing long-term medical conditions such as heart problems, cancer and psychiatric conditions, which are likely to require regular or periodic treatment, medication or advice. This is because the moratorium period starts each time you receive such treatment, so it s unlikely you ll ever have two continuous years free of treatment. Of course, we strongly advise you not to delay seeking medical advice or treatment for a pre-existing condition during the moratorium period. G IMPORTANT INFORMATION DATA PROTECTION NOTICE A copy of our full data protection notice is included in the terms and conditions document. Please ask if you would like to see a copy. VitalityHealth and our business associates, service providers and agents will use your information, together with other information, for administration, customer services, marketing and profiling your purchasing preferences and fraud prevention. We will pass your information to them for these purposes. We will pass your information to any legal or regulatory body if required to do so. By submitting this form you consent to us processing your sensitive personal information; such as health information. We may disclose your personal information to other companies in the Vitality Group*, our business associates, agents or service providers for the purposes above. Your information may be used by service providers in a country outside the European Economic Area, which may not have the same standard of data protection as in the UK. We will ensure appropriate safeguards are in place to protect your information. Acting on someone s behalf? When giving us information about another person, you confirm that they have appointed you to act on their behalf. This includes providing consent to process their personal information, receive this data protection notice on their behalf and receive marketing information. PAGE 4 OF 8

5 G IMPORTANT INFORMATION (CONTINUED) Marketing choice The Vitality Group* of companies and our business associates, service providers and agents would like to use your personal information to inform you of other services and products that may be of interest to you by telephone, post, or text. You can exercise your right to opt out of future marketing campaigns by ticking this box. * The Vitality Group includes Vitality Health Limited and Vitality Health Insurance Limited, both trading as VitalityHealth, and Vitality Corporate Services Limited trading as VitalityHealth and/or VitalityLife. Please continue with this form, ensuring you go to section H to read, sign and date the plan declaration on behalf of all applicants. GENERAL NOTES AND ELIGIBILITY Your cover will not start until we have accepted your application. Please check with your Group Secretary that you can apply to include your dependants to cover. You and all applicants must live in the UK (Great Britain and Northern Ireland, including the Channel Islands and the Isle of Man) for at least 180 days in each plan year. You must be aged 16 or over at the cover start date. Your wife / husband / partner must live at the same address as you and be aged 16 or over at their cover start date. Your children (including adopted children) must be aged 25 or under at their cover start date. Our Worldwide Travel and Emergency Medical Expenses Cover is only available to applicants / existing members providing everyone is aged 79 or under at the plan start date / when the benefit is included to cover. Business Healthcare applicants only: Children aged 21 or over at their cover start date, or the plan renewal date, whichever is sooner, will be charged at an adult rate. If an applicant has a birthday while your application is being processed, the terms may differ from those originally quoted. We may offer revised plan terms, but in certain circumstances we may not be able to offer cover. You should ensure that all applicants are registered with a UK GP and Dentist and that they have your full medical and dental records, if you haven t already done so. This will help avoid delay in getting authorisation for an eligible claim by us. You are entitled to ask for a copy of our standard terms and conditions and a copy of your application form at any time. PAGE 5 OF 8

6 H VITALITYHEALTH PLAN DECLARATION TO BE SIGNED BY THE EMPLOYEE By submitting this application you confirm your understanding of the following: That this application is subject to written acceptance by VitalityHealth. That by completing this application you are applying on behalf of all applicants to be covered on this plan and are doing so with their full consent. You also agree to receive all plan-related documentation on behalf of all applicants. That the information given on this application form must be full and accurate. That you must advise us of any change to the information given in this application which occurs between the date of signing the plan declaration below and the cover start date. That you consent to VitalityHealth using the information supplied for the purposes shown in the data protection notice in section G on pages 4 and 5. That a copy of the application and plan terms and conditions are available on request. Pre-existing medical conditions are subject to the terms and conditions of the moratorium as explained on page 4 and defined in the plan terms and conditions and that these terms will apply to all applicants. If any applicant makes a claim, VitalityHealth will have to request information from them or their GP to determine whether the condition was pre-existing or not. Please therefore ensure that your UK GP has your full medical records to avoid any delay in getting authorisation for a claim by us. This application and the information disclosed on it is valid for 45 days from the date the application is signed (date recorded below). Signature of employee on behalf of all applicants. Date. D D M M Y Y Y Y I APPLICATION CHECKLIST BEFORE YOU RETURN THIS APPLICATION, PLEASE USE THIS CHECKLIST TO CONFIRM THAT YOU HAVE: Completed section A to confirm the basis of your application. Provided your employment, personal (employee), cover and dependants (if applicable) details. Read the Important information in section G. Read, signed and dated the plan declaration in section H. PAGE 6 OF 8

7 NOTES PAGE 7 OF 8

8 VitalityHealth is a trading name of Vitality Health Limited and Vitality Corporate Services Limited. VitalityHealth Limited, registration number is the insurer that underwrites this insurance plan. Vitality Corporate Services Limited, registration number acts as an agent of Vitality Health Limited and arranges and provides administration on insurance plans underwritten by Vitality Health Limited. Registered office at 3 More London Riverside, London, SE1 2AQ. Registered in England and Wales. Vitality Corporate Services Limited is authorised and regulated by the Financial Conduct Authority. Vitality Health Limited is authorised by the Prudential Regulation Authority and is regulated by the Financial Conduct Authority and the Prudential Regulation Authority. PRUHF21789A_0515_ENP_BHC/CHC_EMPLOYEE_MORI Part of the Discovery Group