Private medical insurance Employee application form Full medical underwriting

Transcription

1 Private medical insurance Employee application form Full medical underwriting To be used for plans taken out prior to March 2011 and where the plan number begins with 10. Filling in this form To apply for PruHealth membership, complete parts 1 to 4 (inclusive) using BLOCK capitals and black ink. Please check all details on the application. If any are incorrect, put a line through them and write in the correct details. Any alterations made to this form must be initialled and dated by the employee. Part 1 Eligibility. Who is this form for? You, the employee, aged 16 or over at your cover start date. Your spouse / partner who lives at the same address as you and is aged 16 or over at their cover start date. Your children, including adopted children, who are aged 24 or under at their cover start date. Please note, once included, children can only be covered up to the renewal date on or after their 25th birthday. All applicants must live in the UK (Great Britain and Northern Ireland, including the Channel Islands and Isle of Man) for at least 180 days in each plan year. About you (to be completed by employee) Employer name Company plan number your employment commenced Dr/Mr/Mrs/Ms/Other Forenames Surname Gender M Address F of birth Occupation Postcode Evening phone no. Work phone no. address Requested cover start date D D M M Y Y Y Y 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 became eilgible to apply 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. Please note: If not already registered, all applicants are encouraged to register with a UK GP and dental practitioner who hold their full medical and dental records. This will help avoid delay in getting authorisation for an eligible claim from us. 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 Countrywide Premier Guided Option Phil SLH/1667/0604 Page 1 of 6

2 Part 1, continued Dependants: Spouse / Partner and child details Complete only if there are eligible dependants applying for cover and the Group Secretary has authorised their application. Spouse / Partner s full forenames Surname Gender Your child s full forenames Surname Gender Your child s full forenames Surname Gender Your child s full forenames Surname Gender of birth of birth of birth of birth If you are applying to include more than three dependent children, please attach their details on a separate sheet of paper. Specific Occupations Please enter below the names of any applicants who are employed in the occupations listed (leave blank if this doesn t apply to any applicants): Working offshore in the extraction / refinery of natural / fossil fuels Name of applicant Armed forces personnel (including territorial army) For details of what cover is available for these occupations please contact us. Page 2 of 6

3 Part 2 Health statement Please consider the following questions in relation to you and your family members included on this application form. If you answer Yes to any of the following questions, please complete the relevant section in Part 3 of this form, otherwise it will delay your application. If you do not wish to disclose the answers to your adviser or Group Secretary, you can provide the answers on a separate sheet of paper. Please attach it to this form in a sealed envelope. For the purposes of underwriting (assessing) your application, we usually rely solely on the information you provide on this form. Please help us, therefore, by completing all of the health questions honestly and fully for both yourself and any other applicants. Failure to do so may result in a claim not being paid, your acceptance terms being changed or your cover being cancelled. 1. Have you, or any person to be insured, ever suffered from or asked for advice on any of the following: a) Fainting, fits of any kind, depression, anxiety or any other nervous disorder? Yes No b) Diabetes, gout or any kidney, urinary tract or bladder complaint? Yes No c) Angina, coronary thrombosis, stroke, chest pain, high blood pressure, rheumatic fever or any other disorder of the heart or circulatory system? Yes No d) Cancer? Yes No e) Gynaecological disorders? Yes No 2. In the last 5 years, have you, or any person to be insured, suffered from or asked advice on any of the following: a) Any digestive disorder, gastric or duodenal ulcer or any liver or bowel complaint? Yes No b) Asthma, bronchitis, tuberculosis or any other lung or chest complaint? Yes No c) Bone or muscular problems including back complaints? Yes No d) Varicose veins? Yes No e) Tonsillitis or any other disease or disorder of the ear, nose or throat? Yes No 3. Have you, or any person to be insured: a) Ever been rejected by an insurance company, or been accepted with restrictions/premium increases or had their insurance cancelled? Yes No b) Consulted a doctor or undergone any treatment (including taking drugs or medication) within the last 5 years for any condition not mentioned above? Yes No c) Consulted a specialist or attended a hospital within the last 5 years, either as an in-patient, day-patient or out-patient, for the purpose of an investigation, test, x-ray or operation for any condition not mentioned above? Yes No d) Ever been admitted to a hospital for an illness or as a result of an accident? Yes No e) Had any chronic, long-term medical or dental condition, or is there any known disability, abnormality or recurrent illness or injury which you know or suspect exists? Yes No Page 3 of 6

4 Part 3 Further health history information If you have answered Yes to any of the questions in Part 2, please supply full details below. Please note, failure to provide full details will delay your application: Name of applicant to whom the condition(s) apply Condition/symptom (and question number/letter(s) it refers to) Description of medication/ treatment/consultations/ investigations PLEASE INCLUDE ALL DATES What, if any, further consultations/treatment/ investigations are required Present state of health (e.g. Full recovery or symptoms still present) Additional information - if you require more space, please continue on a separate sheet of paper and attach it to this form. Page 4 of 6

5 Part 3, continued GP s details Please state the name and address of your usual GP (to whom requests for information are usually made). If you have changed your GP in the past year, please also give the name and address of your previous GP on a separate sheet. If the GP is different for any of the other applicants, please also give details on a separate sheet. GP s name Address Postcode Telephone. no. Fax no. Access to Medical Reports Act 1988 Before we can assess your application, we may need to get a medical report from a GP who has cared for you. The Access to Medical Reports Act 1988 gives you certain legal rights. These are: we need your agreement before we can apply for a medical report from your GP. You can refuse but, if you do, we will not be able to assess your application you can ask to see the report before the GP sends it to us, or up to 6 months after if you tick the box below to indicate that you want to see the report, your GP can charge you a reasonable fee to cover costs. This may also delay the assessment of your application if you think part of the report is incorrect or misleading when you see it, you can ask to have it changed. If your GP will not agree to do this, you may attach a statement of your own You will not be entitled to see any part of the report which: the GP believes could seriously harm your physical or mental health, or that of others indicates the GP s intentions in respect of you reveals information about another person, or the identity of someone who has given the GP information about you (unless that person consents or is a health professional involved in caring for you) We will write and tell you when we have requested the report. If you ve asked to see the report before your GP sends it to us, you will have 21 days from the date of receipt of our letter to contact your GP. Once you have seen the report, your GP needs your agreement to send it to us. If you don t arrange to see the report within 21 days, your GP will be free to send it to us. Access to Medical Reports Act 1988 declaration and consent I have been informed of my statutory rights under the Access to Medical Reports Act 1988, as explained above, and in connection with my insurance application hereby consent to PruHealth being provided with medical information from my GP or any other doctor/specialist who at any time has attended me concerning anything which affects my physical or mental health. I agree that a copy of this consent shall have the validity of the original. I wish to see the report before it is sent to PruHealth Please tick one box only I do not wish to see the report before it is sent to PruHealth To avoid delay, each applicant may choose to give their consent by signing in the box below. Your (employee s) signature Signature of partner Parent/guardian (for children under 16) Signature of child (aged 16 or over) Signature of child (aged 16 or over) If we ask your GP for information we will keep you advised and may ask you to contact your GP if we request a medical report and experience delays in receiving it. Page 5 of 6

6 Part 4 PruHealth plan declaration to be signed by employee By submitting this application you confirm your understanding of the following: That this application is subject to written acceptance by PruHealth. 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 failure to take reasonable care in answering any questions may result in a claim not being paid, your acceptance terms being changed or your cover being cancelled. 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 (including changes to any applicants state of health). That no cover will apply for investigations or treatment of any medical condition or related condition which exists or has existed before your cover start date unless, where requested within this application form, you have provided PruHealth with full details and they have agreed to accept it. You also understand that PruHealth will detail on your membership certificate any personal medical exclusion(s) that they ve applied due to the information you have provided. You understand that in certain circumstances PruHealth may be unable to offer cover. That you consent to PruHealth using the information supplied for the purposes shown in the data protection notice below. That a copy of the application and plan terms and conditions are available on request. That you give permission for the medical information you ve provided to be disclosed to any employee in the PruHealth group for risk management and underwriting purposes. This information can also be used to maintain management information for business analysis. That you agree to PruHealth accepting medical reports faxed directly to PruHealth from the GP s surgery of any applicant to be covered by this plan. You also do not object to copies of the report being faxed to any other company that you have applied to at their request. That you have completed the declaration and read the important notes and information relating to your rights under the Access to Medical Reports Act This application and the medical information disclosed on it is valid for 45 days from the date the application is signed (date recorded below). We may need you to confirm there has been no change in health since you signed this form if the final assessment of your application form takes longer than 45 days from the date the application was signed, or in the event we require further medical information from you. In some circumstances a new application form will be required. Signature of employee on behalf of all applicants. Data Protection 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. PruHealth, PruProtect 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 PruHealth 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. Marketing choice PruProtect, PruHealth 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. To be completed by the adviser Agent code Consultant s name For office use only Main plan no. Client code PruHealth is a trading name of Prudential Health Insurance Limited and Prudential Health Services Limited. Prudential Health Insurance Limited, registration number is the insurer that underwrites this insurance plan. Prudential Health Services Limited, registration number acts as an agent of Prudential Health Insurance Limited and arranges and provides administration on insurance plans underwritten by Prudential Health Insurance Limited. Registered office at Laurence Pountney Hill, London EC4R 0HH. Registered in England and Wales. Prudential Health Services Limited is authorised and regulated by the Financial Conduct Authority. Prudential Health Insurance Limited is authorised by the Prudential Regulation Authority and is regulated by the Financial Conduct Authority and the Prudential Regulation Authority. Phil SLH/1667/0604 Page 6 of 6