Members Insurance Application

Transcription

1 Send your application/declaration of health postage free to: Frisvar Förenade Liv Gruppförsäkring AB, Svarspost , Stockholm Members Insurance Application You can fill out your insurance application, direct debit form and declaration of health online! SULF Member since year month Group contract no Member surname, forename Telephone Address Postal code and town Co-insured spouse or partner surname, forename As a new member, you will receive three months of coverage free of charge. See highlighted text below. Accident insurance Member Co-insured Disability compensation (up to) SEK Disability compensation (up to) SEK Disability compensation (up to) SEK Health insurance, members only. Free coverage for three months - valid if under 36 years of age. Monthly salary Monthly compensation (up to) SEK SEK SEK SEK SEK SEK and above SEK Life insurance Death compensation (up to) Income compensation (up to) SEK SEK SEK SEK SEK SEK Child insurance, can only be taken out by members. If you choose an amount over 30 pbb you must fill in a health declaration for all children aged 1 year or more. Diagnostic insurance and medical care cost cover are included. of child(ren) Disability compensation (up to) Premium per month regardless of number of children SEK (20 pbb) 144 kr SEK (30 pbb) 181 kr SEK kr (40 pbb) 228 kr SEK kr (50 pbb) 274 kr FL (FL 1155) Continued on next page forenadeliv.se/sulf

2 Family cover Member Co-insured Monthly death compensation SEK SEK Medical care insurance, members only Please note The amounts stated are for 2015 Please note that certain policies may be subject to restrictions and reduced compensation amounts. For more information, including prices, please see the brochure Your SULF Members Insurance, in the Important Information folder and at forenadeliv.se/sulf Are you fully fit to work? Member Yes No Co-insured Yes No Being fully fit for work means that you: can perform your normal work without restrictions do not receive or are not entitled to compensation in relation to your own illness, accident and/or disability or have such compensation pending. Special qualifications apply to persons receiving in subsidised employment, persons who have been granted leave due to illness in order to seek new work, and persons granted health-related occupation modifications. These restrictions can be found in the Terms and Conditions. Persons who have been granted care allowance or suspended compensation or similar compensation are not considered fully fit to work fully fit to work in relation to medical care insurance. In order to be considered fully fit for work when taking out medical care insurance, the applicant must not have been entitled to compensation for illness and/or accident for more than 14 consecutive days during the last three month period. Applicant s signature Date Work phone (plus dialling code) Home phone (plus dialling code) Member s signature Co-insured s signature forenadeliv.se/sulf

3 Declaration of Health This declaration of health must be completed in person by the applicant. It is important that you answer every question. Send your application/declaration of health in a postage-free envelope to: Frisvar, Förenade Liv Gruppförsäkring AB, Svarspost , Stockholm Name of member (group member) Group contract number Civic registration number Name and surname of co-insured, spouse or partner Civic registration number Are you fully fit to work? Member Yes No Co-insured Yes No In order to be considered fully fit to work, you must be able to perform your normal work without restrictions. Fully fit to work excludes persons who are on any level of sick leave, or receiving sick pay, sickness or rehabilitation benefits, extended sickness benefits, activity compensation, temporary sickness compensation, sickness compensation, or occupational injury annuity at a rate of 50% or more. Persons who have been granted care allowance or suspended compensation are not considered fully fit to work. Special qualifications apply to persons receiving subsidised employment, persons who have been granted leave due to illness in order to seek new work, and persons granted health-related occupation modifications. These restrictions can be found in the Terms and Conditions. If you answer yes to any of questions 1-18, you must provide supplementary information on the back of this form. * sought medical care = e.g. taken sick leave, received care, treatment, monitoring or examination at a hospital, medical centre, treatment clinic or other healthcare institution or contacted a doctor, nurse, physical therapist, chiropractor or naturopathic treatment provider due to conditions/symptoms/illness/ handicaps in one of the following body parts/organs and/or one of the following conditions. Have you sought medical care as defined above* at any time during the past three years due to: Member Co-insured 1. Allergies, asthma and/or any other respiratory illness? Yes No Yes No 2. Skin condition/skin disease? Yes No Yes No 3. Goitre and/or any other metabolic disorder? Yes No Yes No 4. Eye and/or ear disease, tinnitus? Yes No Yes No 5. A condition or disease of the back, neck, shoulders, arms, hips, legs, knees, feet and/or hands? Yes No Yes No 6. A condition or disease of the muscles and/or joints? Yes No Yes No 7. Nervous condition, sleeplessness, stress, burnout, trauma reactions and/or psychiatric illnesses? Yes No Yes No 8. A condition or illness of the stomach, intestinal tract, gall bladder and/or pancreas Yes No Yes No 9. A condition or illness of the urinary tract, kidneys, genitals and/or prostate Yes No Yes No 10. Nutritional, medicinal or insulin treatment for diabetes Yes No Yes No 11. High blood pressure and/or high cholesterol Yes No Yes No 12. A condition or illness of the heart, coronary artery and/or other artery? Yes No Yes No 13. Blood clot/bleeding in the brain and/or another blood vessel Yes No Yes No 14. Epilepsy, dementia, headaches and/or any other neurological condition or illness? Yes No Yes No 15. Tumour and/or a disease of the blood and/or lymphatic system? Yes No Yes No 16. Conditions, symptoms, illnesses, injuries or handicaps not listed in questions 1 15? Yes No Yes No 17. Are you currently taking medication? Yes No Yes No 18. Have you taken more than 14 consecutive days of partial or full sick leave in the past three years? Yes No Yes No 19. Do you smoke? Yes No Yes No 20. Please indicate your height and current weight: cm kg cm kg Authorisation I hereby authorise my doctor or other healthcare professionals, hospitals or other health care institutions, employment agencies, the Social Insurance Office or other insurance agencies to provide any information, log entries or attestations required by Förenade Liv for the processing of this insurance application. This authorisation is also valid for claims adjustments after my death and/or in the event of my inability to issue a new authorisation due to illness, personal injury etc. This authorisation will remain valid until it is revoked or until the matter is resolved. If this authorisation is revoked before the matter is resolved, I am aware that revocation may result in rejection of my application or non-payment of the services applied for. I confirm that all information provided is complete and truthful. I am aware that inaccurate and incomplete information may void my insurance policy. I understand that coverage will take effect only if the application is complete and if the policy is approved by Förenade Liv. Förenade Liv may store any information provided. Date Daytime phone (plus dialling code) Date Daytime phone (plus dialling code) Member signature Signature of co-insured FLG-660

4 Declaration of Health Supplementary information for question no.... of the health declaration Regarding Member Co-insured If you answered yes to more than one question on this health declaration, please copy this form or print more at Name Group contract no. What is your occupation and what are your occupational responsibilities? What is the name of your illness/condition? Your diagnosis? Describe the condition/symptoms in your own words: Cause of condition/symptoms (e.g. accident, illness, work-related) When did your symptom/illness, injury or handicap first appear? year: month: Have you had similar complaints before? Yes No If yes, when? What type of treatment/examination did you receive? Please indicate the name and full visiting address (e.g. department/clinic) of healthcare providers whose services you have used during the past three years. Cause identified/diagnosis? When did you last seek medical care? year month Please indicate your diagnosis and the period of your sick leave as accurately as possible. From until Diagnosis: From until Diagnosis: From until Diagnosis: Please indicate which medicine(s) you are taking: Will you be seeking additional examination or treatment? Yes No If yes, what type? Are you symptom-free? Yes No If yes, when did you become symptom-free? year: month: If you are not symptom-free, what remaining symptoms/conditions are you experiencing? Authorisation I hereby authorise my doctor or other healthcare professionals, hospitals or other health care institutions, employment agencies, the Social Insurance Office or other insurance agencies to provide any information, log entries or attestations required by Förenade Liv for the processing of this insurance application. This authorisation is also valid for claims adjustments after my death and/or in the event of my inability to issue a new authorisation due to illness, personal injury etc. This authorisation will remain valid until it is revoked or until the matter is resolved. If this authorisation is revoked before the matter is resolved, I am aware that revocation may result in rejection of my application or nonpayment of the services applied for. I confirm that all information provided is complete and truthful. I am aware that inaccurate and incomplete information may void my insurance policy. I understand that coverage will take effect only if the application is complete and if the policy is approved by Förenade Liv. Förenade Liv may store any information provided. Date Signature FLG-660

5 Health Declaration Child under 18 To be completed by a custodian who is applying for child insurance for a child aged under 18. "Important to know" in "Important information" indicates when a health declaration needs to be submitted. The health declaration for a child who has reached the age of 18 can be found at forenadeliv.se. It is important to answer all questions. Group agreement number Name of member/employee (group member) Name of child If the answer to any of questions 4-22 is "Yes", supplementary information must be given on the attached form. 1. Birth weight (for children aged under 6) grams 2. Birth week (for children aged under 6) Week: 3. Present height and weight cm kg 4. Were there any complications in connection with labour or during the first month after birth? Yes No 5. Has anything particular arisen during checks at the children's health centre (BVC) or school health care? Yes No 6. Does the child receive any special help at childminder/ pre-school/ school? Yes No 7. Have care contributions been applied for? Yes No Have any health care services been used (e.g. prescription, nursing, treatment, hospital examinations or checks, health care centre, treatment centre or other care institution, or any other contact made with a doctor or nurse, physiotherapist etc. due to conditions/symptoms/illness/handicap in respect of any of the organs or conditions mentioned below) during the last five years, due to: 8. allergy, asthma? Yes No 9. eczema, skin condition, skin disease? Yes No 10. metabolic disorder, diabetes? Yes No 11. illness/condition of the eye, ear/nose/throat? Yes No 12.Musculo-skeletal disorders? Yes No 13. mental condition/illness, behavioural disorders (e.g. ADHD, eating disorders)? Yes No 14. condition/illness of the stomach, intestines, inner organs? Yes No 15. condition/illness of the urinary tract, kidneys? Yes No 16.delayed speech development or other delayed development? Yes No 17. condition/illness of the heart or vascular system? Yes No 18. cerebral haemorrhage or blood clot? Yes No 19. epilepsy or other neurological symptoms/illnesses? Yes No 20. tumour, diseases of the lymphatic glands or blood? Yes No 21. Has the child taken medicine for any condition or illness other than those mentioned above? Yes No 22. Does the child have any condition, symptom, illness or injury or handicap other than those mentioned in questions 1-21? 23. Is the child adopted? If "Yes" attach the result of the adopted child control. State name and address of children's health centre (BVC): Yes Yes No No Declaration I confirm that the information provided is entirely truthful. I am aware that incorrect or incomplete information could render the insurance invalid. I am aware that the insurance will only enter into force if the application is complete and insurance can be granted by Förenade Liv. Date Daytime phone (plus dialling code) Date Daytime phone (plus dialling code) Custodian's signature Custodian's signature FLG-693

6 Health Declaration Child under 18 Supplementary information to question No.... in the health declaration Please copy this form if you have answered Yes to more than one question Name of child What is the name of the illness/condition? Diagnosis? When did the symptom, illness, injury or handicap first occur? What examination/treatment has the child had? year: month: State what medicine(s) the child is taking: Will there be further check-ups or treatment? Yes No If the answer is "Yes", of what kind? Is the child free of symptoms? Yes If the answer is "Yes", when did the child become free of symptoms? year: month: No If the child is not free of symptoms, what injuries/conditions/symptoms remain? State the name and complete surgery address, department/clinic of health care services used during the last 5 years. Cause/diagnosis? When was this health care service last used? year month State the name and complete address of the children's health centre (BVC) to which the child belongs (for children aged under 6). State the name and complete address of the school health care service to which the child belongs (for children aged over 6). Declaration I confirm that the information provided is entirely truthful. I am aware that incorrect or incomplete information could render the insurance invalid. I am aware that the insurance will only enter into force if the application is complete and insurance can be granted by Förenade Liv. Date Daytime phone (plus dialling code) Date Daytime phone (plus dialling code) Custodian's signature Custodian's signature FLG-693

7 Yes! I wish to pay by direct debit You can also register for direct debit at forenadeliv.se/autogiro Policyholder s name Agreement number Daytime phone (plus dialling code) Name of bank Clearing code Account number If you are paying through an account other than your own, give the payer s name and civic registration number below. Name, other payer I approve the conditions for payment to Förenade Liv by direct debit Date Signature (policyholder) Date Signature (other payer) Conditions for Förenade Liv direct debit Mandate for payment by direct debit (Autogiro) The undersigned ( the payer ), consents to payment being made by withdrawal from the account indicated or an account indicated by the payer at a later time on request of the indicated payee for payment to the payee on a certain date ( the due date ) through Autogiro. The payer consents to processing of personal data provided in this mandate being handled by the payer s payment service provider, the payee, the payee s payment service provider and Bankgirocentralen BGC AB for the administration of the service. Personal data managers for this personal data processing are the payer s payment service provider, the payee and the payee s payment service provider. The payer may at any time request to receive access to or correction of the personal data by contacting the payer s payment service provider. Further information regarding the processing of personal data in connection with payments may be found in the terms and conditions for the account and in the agreement with the payee. The payer can at any time revoke his or her consent, which concludes the service in its entirety. Description General Autogiro is a payment service that means that payments are carried out from the payer s account on the initiative of the payee. For the payer to be able to pay through Autogiro, the payer must provide his or her consent to the payee that the payee may initiate payments from the payer s account. In addition, the payer s payment service provider (e.g. bank or payment institution) must approve that the account can be used for Autogiro and the payee must approve of the payer as a user of Autogiro. The payer s payment service provider is not obliged to check the authorisation of or notify the payer of requested withdrawals in advance. Withdrawals are charged to the payer s account in accordance with the rules that apply at the payer s payment service provider. The payer receives notification of withdrawals from his or her payment service provider. On request of the payer, the mandate can be transferred to another account with the payment service provider or to an account with another payment service provider. Definition of banking business day A banking business day refers to all days except Saturday, Sunday, Midsummer s Eve, Christmas Eve or New Year s Eve or another public holiday. Information on payment The payer will be notified by the payee of the amount, due date and means of payment no later than eight banking business days before the due date. This can be notified prior to every individual due date or on one occasion concerning several future due dates. If the notification refers to several future due dates, the notification must be made no later than eight banking business days before the first due date. However, this does not apply to cases in which the payer has approved the withdrawal in conjunction with a purchase or order of a product or service. In such a case, the payer receives a notice from the payee regarding the amount, due date and means of payment in conjunction with the purchase and/or the order. By signing this mandate, the payer provides his or her consent to payments covered by the payee s notification in accordance with this section being carried out. Sufficient funds must be available in the account The payer must ensure that sufficient funds are available in the account no later than 00:01 on the due date. If the payer does not have sufficient funds in the account on the due date, it may mean that payments cannot be carried out. If sufficient funds are unavailable for payment on the due date, the payee may make additional withdrawal attempts during the coming banking business days. The payer can receive information from the payee upon request regarding the number of withdrawal attempts. Stop payment (revocation of payment order) The payer may stop a payment by contacting either the payee no later than two banking business days before the due date or his or her payment service provider no later than the banking business day before the due date at the point in time indicated by the payment service provider. If the payer stops a payment as per the above, it means that the current payment is stopped on a single occasion. If the payer wants all future payments initiated by the payee to be stopped, the payer must revoke the mandate. Mandate s period of validity, revocation The mandate is valid until further notice. The payer has the right to revoke the mandate at any time by contacting the payee or his or her payment service provider. In order to stop payments not yet carried out, the notice of the revocation of the mandate must be received by the payee no later than five banking business days before the due date or be received by the payer s payment service provider no later than the banking business day before the due date at the point in time indicated by the payment service provider. The right for the payee and the payer s payment service provider to end the connection to Autogiro. The payee has the right to end the payer s connection to Autogiro 30 days after the payee has notified the payer thereof. However, the payee has the right to immediately end the payer s connection to Autogiro if the payer on repeated occasions does not have a sufficient account balance on the due date, if the account to which the mandate pertains is closed or if the payee deems that the payer should not participate in Autogiro for another reason. The payer s payment service provider has the right to end the payer s connection to Autogiro in accordance with the terms that apply between the payer s payment service provider and the payer. forenadeliv.se/sulf

8 No, I do not wish to keep the following insurance policies. As a new member you are automatically covered by the insurance policies below. Coverage can be cancelled up to 2 months after joining SULF Accident insurance I wish to cancel the accident insurance. Health insurance (for those aged under 36) I wish to cancel the health insurance. I am not eligible for health insurance because I am not or have not been fully fit to work in accordance with the eligibility requirements in the welcome letter. Life insurance I wish to cancel the life insurance. I am not eligible for life insurance because I am not or have not been fully fit to work in accordance with the eligibility requirements in the welcome letter. Medical care insurance Plus I wish to cancel the medical care insurance. I am not eligible for medical care insurance because I am not or have not been fully fit to work in accordance with the eligibility requirements in the welcome letter. Member s signature Date Signature Civic registration number Förenade Liv Gruppförsäkring AB Stockholm kundservice@forenadeliv.se Customer service Telephone: Fax: