Global Health Plans Corporate Application Form (3-9 Employees)

Transcription

1 Global Health Plans Corporate Application Form (3-9 Employees) Please complete this form in BLOCK CAPITALS using black ink, and return it to us by , fax or post. You can find our contact details at the end of this form. Company details Company name: Nature of business: Address:... Telephone number: Contact(s) at company Contact 1: Position in company: Telephone number: Contact 2: Position in company: Telephone number: Start date required When would you like your Global Health plan to start? On acceptance of your application Specific date:... Please note that your application is only valid for 28 days from the date we receive it. We cannot commence your plan until we have accepted your application and received payment of your first premium. If cover has not commenced within 28 days of receipt of your application, we reserve the right to request a new one. Cover cannot be backdated. Please choose either an Elite plan or a Foundation plan, then select the optional benefits you require. A) Elite plans Quote illustration number (for the quote you wish to accept):... Plan: Excess required: GOLD Nil $15 or AED 55 per visit $30 or AED 110 per visit SILVER Nil $15 or AED 55 per visit $30 or AED 110 per visit Neuron medical network required Comprehensive (widest network of medical facilities) General Plus (excludes some of the more expensive facilities) Additional benefits available with the Elite plans Routine dental care benefit only available with Elite Silver $5,000 or AED 18,350 maternity care benefit only available with Elite Silver $7,000 or AED 25,690 maternity care benefit only available with Elite Silver Complex dental care benefit only available with Elite Gold Optical care benefit only available with Elite Gold 1

2 Choose your Elite Area of Cover Area One Provides worldwide cover, excluding the USA Area Two Provides worldwide cover, with cover in the USA limited to $100,000 during temporary trips of not more than 45 days Area Three Provides worldwide cover, with cover in the USA limited to $250,000 during temporary trips of not more than 90 days B) Foundation plans Quote illustration number (for the quote you wish to accept):... Plan: Excess required: FOUNDATION PLUS Nil FOUNDATION Nil Neuron medical network required General (basic network of medical facilities) The Foundation Areas of Cover The Foundation plan provides cover in the UAE and the Indian Subcontinent (India, Pakistan, Sri Lanka, Bangladesh, Nepal & Bhutan). Insured persons are not covered for treatment received in their home country if that country is not stated above. The Foundation Plus plan provides worldwide cover, excluding the USA, Canada, Caribbean Island & Countries, and the London area. Cover is restricted in the following countries and regions: all countries within the European Union, Andorra, Channel Islands, Gibraltar, Iceland, Liechtenstein, Monaco, Norway, San Marino, Switzerland, Australia, Bali, China, Hong Kong, Japan, Macau, New Zealand, Singapore, and Taiwan. By restricted we mean that the cover we provide is restricted to emergency treatment you receive whilst on a temporary trip of up to 90 days to one of the restricted countries or regions stated above. The maximum benefit we will pay in respect of all emergency treatment you receive in restricted countries or regions during an annual period of cover is $50,000. Optional benefits available with the Elite and Foundation plans GLOBAL TRAVEL PLAN Employees Spouses/partners Families GLOBAL PERSONAL ACCIDENT PLAN Employees Spouses/partners Please answer the questions below ONLY if you have opted for Personal Accident cover. If you have opted for cover for the spouses/partners of your employees, we also require details of their occupation and any hazardous activities. Please select level of Personal Accident benefit you require: $75,000 or AED 275,250 $150,0000 or AED 550,500 $225,000 or AED 825,750 $300,000 or AED 1,101,000 $375,000 or AED 1,376,250 The Global Personal Accident plan does not cover accidents as a result of hazardous activities/occupations. Cover for hazardous activities/occupations may be subject to a premium loading, special terms, or we may decline to offer cover. Eligibility for cover for your plan Cover must be provided and paid for by the company on a compulsory basis. The company must apply for cover for ALL employees, or ALL employees of a certain category (for example all employees who are managers). If cover for employees dependants is required, the company must apply for cover for ALL eligible dependants. 2

3 Please state the total number of persons employed by the company:... Please state below the eligibility criterion for membership of your plan: 1. Cover is for ALL employees of the company 2. Cover is ONLY for a certain category of employee If, is cover required for their eligible dependants? If, is cover required for their eligible dependants? If the answer to question 2 is, please state the category of employee to be insured: Paying for your plan Please select the currency in which you would like to pay your premiums: US Dollars Dirhams Your plan benefits and excess will be denominated in the currency in which you pay your premiums. Please select your payment method and frequency: Bank transfer Annually Half-yearly Quarterly Monthly* Cheque** Annually Half-yearly Quarterly Monthly* *Monthly payments are only possible if you are paying in US Dollars. ** Cheques are payable to Dubai Insurance Company psc., and must be drawn on a UAE bank account. Half-yearly premiums are subject to a 3% surcharge. Quarterly or monthly premiums are subject to a 5% surcharge. Broker details If you were introduced to us by an intermediary or broker, please state their name, company and PHIR number. Name of broker:... Name of company:... PHIR no.:... Declaration for the Global Health plan Please read this section carefully and sign below. We understand that this application is subject to written acceptance by Dubai Insurance Company psc. We declare that we have taken reasonable care to answer all questions fully, accurately, and to the best of our knowledge and belief. We understand that misrepresentation could result in claims being rejected or not fully paid, and/or our plan being cancelled. We understand that we must inform Dubai Insurance Company psc., in writing, of any changes in the facts provided in this application. We agree that this declaration and the answers provided on this application form shall form the basis of the contract between ourselves and Dubai Insurance Company psc., and that this application form, together with the relevant Plan Agreement(s) and the Certificates of Insurance, shall form the contract of insurance. We understand that, upon receipt of our insurance documents, if we am not entirely satisfied, we can cancel our application from inception and receive a full refund of the paid premium, provided we notify Dubai Insurance Company psc. within 30 days of the plan start date, and provided no claim has been made. 3

4 Important notes Please provide the following documentation with your application: Photographs of each member in JPEG format A full census of all members, including the passport number, Emirate ID number, and UID number for each member A copy of your company s trade license Name of company representative (1):... Signature of company representative (1):... Date:... Name of company representative (2):... Signature of company representative (2):... Date:... The Global Health plans are designed by William Russell Limited and insured by Dubai Insurance Company psc., who are licensed by the UAE Insurance Authority, registration number 4. The claims service for the Global Health plan range is administered by Neuron LLC. The Global Travel plans and Global Personal Accident plans are designed by William Russell Limited and insured by Dubai Insurance Company psc., who are licensed by the UAE Insurance Authority, registration number 4 DIC/2016/group_h_app/v1 Global Plans Team Dubai Insurance Company, PO BOX 3027, Dubai, UAE T: F: E: enquiries@globalplans.ae globalplans.ae

5 Global Health Plans Application for Neuron Services Please complete this form in BLOCK CAPITALS using black ink, and return it to us by , fax or post. You can fi nd our contact details at the end of this form. Important information about the Neuron claims service Neuron LLC administers the claims service for the Global Health plans. All insured persons receive a network membership card from Neuron, which allows them to receive eligible treatment from the medical facilities in Neuron s extensive network. By eligible treatment, we mean treatment covered under the Global Health plans, subject to any applicable benefi t limits. When an insured person presents their network card to a medical facility within their chosen Neuron network, the medical facility will request a form of identifi cation in order to verify that the person is indeed insured. Once verifi ed, the medical facility will only ask the insured person to pay the excess amount displayed on the network card. Treatment will be provided without the insured person having to make any other form of payment. The bill for the medical treatment will be sent straight to Neuron, who will settle directly with the medical facility. Neuron is obliged to settle all bills received from medical facilities within their network. This means that insured persons have an obligation only to use their network card for eligible treatment covered under their Global Health plan. If an insured person is in any doubt about what is eligible, they should contact Neuron or our Claims Team before they receive treatment. It is very important that you and all insured persons understand the obligations of using the Neuron claims service. When an employee leaves your company When an employee leaves your company, you must retreive their Neuron network card and all cards issued to dependants as soon as possible. If you do not retreive the cards, they could be used to claim for medical treatment. Your company will be liable for any costs incurred by an employee (and any dependants) after the date they leave your employment. As such, we will only cancel an employee s cover from the date on which we receive their returned network card(s) from you. You will be charged a premium for the employee (and dependants) until the network card(s) are returned to us. Dubai Insurance Company psc. are entitled to recover from your company all costs and/or liabilities incurred after the date your employee (and dependants) leave your employment. When an insured person claims for treatment not covered by your plan When an insured person presents their Neuron network card for a treatment or service that is not covered by your Global Health plan, you will be liable for any costs incurred. For example, this situation could arise if an insured person uses their network card to pay for the treatment of a medical condition that is not eligible for benefi t under your Global Health plan, or if the treatment costs incurred exceed any applicable benefi t limits. Your company will be responsible for any ineligible claims made by an insured person. As soon as we are made aware of an ineligible claim, we will write to the insured person and ask them to repay to us the ineligible costs. If that person fails to repay those costs, we will require their network card immediately. Your company agrees to indemnify fully Dubai Insurance Company psc. if we are unable to obtain repayment of ineligible costs from the insured person within 30 days. If an insured person makes more than one ineligible claim, we will require their network card immediately along wtih any cards issued to dependants. Future claims must be submitted to our Claims Team for consideration. Requirement for photographic identification To produce network cards, we require a photograph of each insured person to be displayed on their card. Please submit a photograph for each insured person in JPEG format. We are unable to issue any network cards until we have received all photographs. Insured persons will not have access to the Neuron direct billing networks until this is done. In submitting these photographs, you give us permission to reproduce the images on the respective network cards. Declaration We hereby apply for membership of our chosen Neuron network. We understand that each insured person must submit a photograph in JPEG format, and this photograph will be displayed on each insured person s network card. We understand that the Global Health plan cannot commence until Dubai Insurance Company psc. has received photographs for all insured persons. We fully understand the important information provided above about the Neuron claims service. We will inform Dubai Insurance Company psc. immediately of any employees (and dependants) who leaves the company, and we agree to retrieve the network card(s) as soon as possible. We understand that any credit issued by Dubai Insurance Company psc. in respect of any premium refund following an employee

6 (and dependants) leaving your company will be calculated from the date that the relevant network cards are received by Dubai Insurance Company psc. We will ensure that all insured persons are fully aware of the benefi ts covered under their Global Health plan, as well as all treatments and conditions that are not covered, or which are subject to certain limits, to avoid incorrect claiming on their network cards. Company name:... Plan number:... Name:... Position/title:... Signature:... Date:... The Global Health plans are designed by William Russell Limited and insured by Dubai Insurance Company psc., who are licensed by the UAE Insurance Authority, registration number 4. The claims service for the Global Health plan range is administered by Neuron LLC. The Global Travel plans and Global Personal Accident plans are designed by William Russell Limited and insured by Dubai Insurance Company psc., who are licensed by the UAE Insurance Authority, registration number 4 DIC/2016/group_neuron_app/v1 Global Plans Team Dubai Insurance Company, PO BOX 3027, Dubai, UAE T: F: E: enquiries@globalplans.ae globalplans.ae