BUPA DENTAL PLAN A P P L I C AT I O N F O R M

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1 BUPA DENTAL PLAN A P P L I C AT I O N F O R M

2 Please cmplete all relevant sectins f the frm in BLOCK CAPITALS and BLACK INK and return it t: Cnsumer Partnerships, FPS Dental, Bupa, Willw Huse, Chertsey Lane, Staines, Middlesex, TW18 3DZ. Yur persnal details Title: (Mr, Mrs, Miss, Ms, ther title) Surname: First name(s): Address: Pstcde: Date f birth: Telephne number (day): Telephne number (evening): Cmpany name: Bupa grup number: Frces Pensin Sciety If previus Bupa member please give membership n. Bupa Dental Plan Please tick yur chsen level f cver. Cre Level 1 Scheme start date Level 2 Level 3 Level 4 Methd f payment Variable Direct Debit* Mnthly Annually Cheque (made payable t Bupa) *Please cmplete the Direct Debit instructin ppsite N/A Yur family s details (if yu wish t add family members t yur plicy) First name, ther initials and surname: Relatinship t yu (eg partner/sn/daughter) Please include any additinal dependants n a separate sheet and indicate that yu have dne s by ticking this bx: Date f birth day mnth year

3 Yur legal Declaratin Imprtant: Please read this declaratin carefully befre signing and dating the cmpleted frm. 1. i am applying fr a Bupa dental plan. I agree that the terms f cver set ut in the current membership guide relating t my cver (which is the cver fr which I am nw applying) will be binding n me and any dependants cvered under my membership, and accept they shall be the basis upn which benefits shall be payable under my cver. (The membership guide fr yur cver will be psted t yu if we accept yur applicatin and is available n request.) 2. i declare that all the infrmatin given t Bupa n behalf f myself and my dependants fr the purpses f receiving my qutatin and being cvered by Bupa and the infrmatin cntained in this applicatin fr Bupa membership is and remains true and cmplete, t the best f my knwledge and belief, except t the extent I infrm yu therwise when sending yu this applicatin fr Bupa membership. I have cnfirmed the details f my dependants with the relevant family member. 3. i agree t infrm Bupa if any f the infrmatin relating t myself r any dependants I have prvided, r prvide, changes at any time befre cver starts. 4. i understand that if the infrmatin I prvide r have prvided t Bupa and the infrmatin in this applicatin fr Bupa membership cntains any material gaps r missins, Bupa may terminate my cver r benefits might nt be payable. (A material gap r missin is a failure t prvide any infrmatin abut yurself r yur dependants that might influence ur assessment r acceptance f yur membership such as terms f the cver we ffer yu, yur subscriptin figure, r whether we ffer cver at all. If yu re unsure whether any particular fact is material r nt, yu shuld disclse it t us. Yu must ensure that any details prvided abut yur dependants are crrect.) 5. i understand that I will have the ptin f cancelling my Bupa cver, as lng as I d s in writing within 21 days f me receiving my membership certificate and n claims have been paid. 6. i cnfirm that I give explicit cnsent, within the prvisins f the Data Prtectin Act 1998, n behalf f myself and any family members specified in this frm fr Bupa t prcess ur persnal infrmatin with respect t ur membership and I cnfirm that I have brught the Data Prtectin Ntice t the attentin f these family members. 7. i understand English Law applies t the agreement between me and Bupa, unless therwise agreed between us in writing. 8. i understand any agreement with Bupa t prvide Bupa cver t me and my dependants is made n the basis f this legal declaratin. Yu are advised t keep a recrd f all infrmatin yu supply t us in cnnectin with yur Bupa membership, including this applicatin frm and any letters. If yu wuld like a cpy f this frm please ask us. Signature Date

4 Data Prtectin Ntice Cnfidentiality: The cnfidentiality f patient and member infrmatin is f paramunt cncern t the cmpanies in the Bupa Grup. T this end, we fully cmply with Data Prtectin Legislatin and Medical Cnfidentiality Guidelines. Bupa smetimes uses third parties t prcess data n its behalf. Such prcessing, which may be utside f the Eurpean Ecnmic Area, is subject t cntractual restrictins with regard t cnfidentiality and security in additin t the bligatins impsed by the Data Prtectin Act. Medical infrmatin: Medical infrmatin will be kept cnfidential. It will nly be disclsed t thse invlved with yur treatment r care, including yur GP r t their agents and if applicable, t any persn r rganisatin wh may be respnsible fr meeting yur treatment expenses, r their agents. Member details: All membership dcuments and cnfirmatin f hw we have dealt with any claim yu may make will be sent t the main member. Telephne calls: In the interest f cntinuusly imprving ur services t members, calls may be recrded and may be mnitred. Research: Annymised r aggregated data may be used by us, r disclsed t thers, fr research r statistical purpses. Fraud: Infrmatin may be disclsed t thers with a view t preventing fraudulent r imprper claims. Names and addresses: Bupa des nt make the names and addresses f members available t ther rganisatins. Keeping yu infrmed: the Bupa Grup wuld, n ccasin, like t keep yu infrmed f The Bupa Grup s prducts and services which we cnsider may be f interest t yu. Cntact address: If yu d nt wish t receive infrmatin abut ur prducts and services, r have any ther Data Prtectin queries, please write t the Bupa Grup s Head f Infrmatin Gvernance at: Bupa Huse, Blmsbury Way, Lndn WC1A 2BA r at: Instructin t yur Bank r Building Sciety t pay by Direct Debit Please cmplete the white areas in BLOCK CAPITALS and BLACK INK t instruct yur bank t make payments directly frm yur accunt. Then return the cmpleted frm t: Cnsumer Partnerships, FPS Dental, Bupa, Willw Huse, Chertsey Lane, Staines, Middlesex, TW18 3DZ. Originatr Identificatin Number Name and full pstal address f yur Bank r Building Sciety branch Bupa reference/membership number T: The Manager Bank r Building Sciety Address Name(s) f accunt hlder(s) Branch srt cde Bank r Building Sciety accunt number Pstcde Declaratin I/we instruct yu t pay direct debits frm my/ur accunt at the request f Bupa. The amunts are variable and may be debited n varius dates. I/we understand that Bupa may change the amunts and dates nly after giving prir ntice. I/we will infrm the bank/building sciety in writing if I/we wish t cancel this instructin. I/we understand that if any direct debit is paid which breaks the terms f this instructin, the bank/building sciety will make a refund. Signature(s) Date Banks and Building Scieties may nt accept Direct Debit Instructins fr sme types f accunt. Bank cntact address: Bupa, Anchrage Quay, Salfrd Quays M50 3XL. This Guarantee shuld be detached and retained by the payer. The Direct Debit Guarantee This Guarantee is ffered by all banks and building scieties that accept instructins t pay Direct Debits. If there are any changes t the amunt, date r frequency f yur Direct Debit Bupa will ntify yu 10 wrking days in advance f yur accunt being debited r as therwise agreed. If yu request Bupa t cllect a payment, cnfirmatin f the amunt and date will be given t yu at the time f the request. If an errr is made in the payment f yur Direct Debit by Bupa r yur bank r building sciety yu are entitled t a full and immediate refund f the amunt paid frm yur bank r building sciety. If yu receive a refund yu are nt entitled t, yu must pay it back when Bupa asks yu t. Yu can cancel a Direct Debit at any time by simply cntacting yur bank r building sciety. Written cnfirmatin may be required. Please als ntify us.

5 Bupa Dental Plan is prvided by Bupa Insurance Limited. Registered in England and Wales N * Bupa Insurance Services Limited. Registered in England and Wales N * *Authrised and regulated by the Financial Services Authrity. Registered Office: Bupa Huse, Blmsbury Way, Lndn WC1A 2BA. Bupa 2013 Care hmes Cash plans Dental insurance Dental services Health assessments Health at wrk services Health caching Health infrmatin Health insurance Hme healthcare Internatinal health insurance Travel insurance DP/4412/FEB13 - FPS bupa.c.uk

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