Generali Worldwide Group Health Insurance Health Insurance Application Form

Transcription

1 Geerali Worldwide Group Health Isurace Health Isurace Applicatio Form Please complete all sectios i BLOCK CAPITALS or tick the boxes, where appropriate. A completed Health Isurace Applicatio is required for all ew applicats for coverage, for ay previous member who has had a gap i coverage, ad for ay applicats who are requestig a icrease i or sigificat chage to existig coverage. I additio to this form, a medical examiatio is required for ay applicat(s) age 60 ad over, ad ay applicats requestig Life Isurace i excess of $100,000. Employer Istructios Employers should complete Sectio A. After you have completed Sectio A, give the form to your employee to complete Sectio B. They may either retur this directly to Iteratioal Healthcare Solutios, Geerali Worldwide s represetative i Cayma (i perso, via fax or ), or retur to you to provide to IHS/ Geerali Worldwide o their behalf. Employee Istructios Please cofirm that your details i Sectio A are correct, the complete Sectio B. Please be sure that all questios are completely aswered, providig dates ad details as appropriate. Be certai that oly the ames of idividuals requestig coverage (you ad ay depedats) are listed. Sig ad retur the completed form to Iteratioal Healthcare Solutios or your Huma Resources Represetative. If you are requestig coverage for your spouse they must sig the form as well. Please ote: if you are required to obtai a medical or other exam to satisfy our requiremets of isurability you will be resposible for the cost. SECTION A To be completed by the employer Please complete the followig sectio. If you are ot a existig employer, please write N/A i #1. 1. Employer Group Number: 2. Employer/ Compay Name: 3. Employer mailig address: 4. Employer physical address (if differet from mailig address): 5. Employer phoe umber: Fax umber: address: 6. Employee Name: 7. Employee date of hire: 8. Employee job title: 9. Requested Effective Date: 1 of 6 Geerali Worldwide Isurace Compay Limited Group Health Isurace Health Isurace Applicatio Form

2 10. If employee is curretly covered by Geerali Worldwide, what is their member idetificatio # or the compay ame? 11. Please idicate if you are requestig: Global WorldChoice CaymaChoice ClearChoice Deductible amout chose: 12. Requested group life amout: $10,000 $50,000 2 X salary to $100,000 (list salary below) Aual Salary: U.S. Dollars $ per year ad C.I. Dollars $ per year I certify that the above iformatio is correct Authorized Employer Represetative Sigature: Date: SECTION B To be completed by the employee Please complete the followig sectio. Please type or prit clearly i ik. 1. Employee Cotact Iformatio: Home Phoe: Cell Phoe: Work Phoe: Address: 2. Have you ever applied for coverage with Geerali Worldwide? Whe? 3. Has the employee bee isured for the past 12 moths i Cayma by a approved isurer with o breaks i coverage for more tha 3 moths? Name of isurer: If yes, provide the startig date: ad the edig date: 4. Number of sick days i the last full caledar year: 5. Locatio of Depedats: 6. Persoal Details: Name(s) of perso(s) to be covered Previous Geerali Worldwide ID # (if ay) Birth Date mm/dd/yy Citizeship Geder (male or female) Height (idicate ft/ iches) Weight (idicate pouds) a) employee b) spouse c) child d) child e) child f) child 2 of 6 Geerali Worldwide Isurace Compay Limited Group Health Isurace Health Isurace Applicatio Form

3 7. Please aswer the followig questios ad provide details where requested if coverig childre: If ay depedat, age 19 or older, requires coverage, are they attedig school full-time? If Yes, please attach proof of studet status. Is ay depedat of applicat actively employed? If Yes, give ame of the employer ad other isurace details: Is ay applicat covered uder aother health isurace icludig free care at govermet facilities? If Yes, ame of other Isurace Compay: ad the Name of ID & Effective Date: Policyholder: Number: (MM/DD/YY) Do all depedat childre requirig coverage live i your household? If No, provide cotact details: 8. Statemet of Geeral Health: Aswer the followig questios for ALL applicats. Give complete details for Yes aswers usig the space provided uder #12. a. Is ay applicat pregat? If Yes, expected delivery date: b. Are ay medical/ surgical or detal procedures (icludig x-ray, lab or other testig) recommeded, scheduled ad/or cotemplated for ay applicat? c. Is ay applicat takig prescribed medicatios (icludig birth cotrol) for ay coditio or has ay medicatio/ treatmet bee prescribed durig the last 6 moths? If Yes, list idividual(s) ame: Medicatio: Dosage: Duratio: Diagosis: d. Does ay applicat use tobacco products (icludig cigarettes, cigars, pipes, etc or chewig tobacco)? Idicate which applicat: Packs per day: # of years used: e. Icludig work permit exams, withi past 5 years has ay applicat bee examied by, cosulted with, or received medical treatmet from ay doctor, detist, or other medical provider? f. Withi the past 5 years, has ay applicat bee cofied (stayed overight) i hospital, cliic, saatorium or other treatmet facility? 3 of 6 Geerali Worldwide Isurace Compay Limited Group Health Isurace Health Isurace Applicatio Form

4 g. Has ay applicat ever bee deied life, disability, medical or detal or ay group coverage or offered coverage with a exclusio for a specific coditio? If Yes, list applicat ame ad details: 9. Has ANY applicat had ay disease or impairmet of or suffered ay symptoms or required ay medicatio, treatmet or hospital cosultatio(s) for the medical coditios below? Please check YES if applicat has ay history of the followig problems. Please check NONE if o history of ay of the listed problems exists. For all YES aswers please provide complete details regardig the coditio, etc uder #12. History of Prior/ Curret Medical Coditios Noe YES YES YES AIDS/ ARC/ HIV Cholesterol Metal/ Nervous Disorder Alcohol depedecy or drug/ substace abuse Cystic Fibrosis Neurological/ Nervous System Aaemia or ay other blood disorder Detal/ Gum Disease Paralysis Arthritis, or ay disorder of ay muscles, boes or joits Diabetes Prostate Asthma, brochitis or ay other respiratory disorder Ears, eyes, ose or throat Rheumatic Fever Back/ Spie/ Neck Epilepsy, covulsios, seizures, fits Reproductive Disorder or Ifertility Blood Pressure/ Hypertesio Gastroitestial (stomach/ itesties) Sexually Trasmitted Disease Blood Vessels/ Clots/ Circulatory system Gout Ski Boes (icludig fractures) Heria Sleep Disorder Brai/ Head Immue System Disorder Stroke Cacer, tumour, growth or cyst Ijury, operatio, physical defect or deformity Surgical Operatio Carpal Tuel Sydrome Kidey/ Bladder/ Uriary Tract Thyroid or Edocrie System Cerebrovascular Disease/ Disorder or Stroke Chest pais, palpitatios, heart murmur, agia, heart attack, ay other heart disorder Liver, gall-bladder, pacreas or splee Ulcer Lugs/ Breathig Uriary Abormality Other medical impairmet ot listed 10. Is there a oral/ detal coditio(s) eedig treatmet (other tha ormal cleaig & routie exams) by ay applicat requestig coverage? If Yes, give full details uder #12 below (e.g. umber of filligs, crows, extractios, missig teeth, surgery, orthodotic treatmet, etc). 11. Does ay idividual(s) have a kow physical impairmet(s) or ill health ot metioed i Sectios 9 & 10? If Yes, give full details uder #12. 4 of 6 Geerali Worldwide Isurace Compay Limited Group Health Isurace Health Isurace Applicatio Form

5 12. Use this space to provide details for your aswers ad medical issues/ visits idetified i umbers If you eed more space, provide full details o a separate sheet ad retur it with your applicatio. Applicat Name What was wrog? Dates mm/dd/yy What was doe to help? Doctor s Name How is the problem ow? If the visits above were routie i ature ad o follow up is required, please check here: Life/ AD&D Beeficiary Name(s) (First, Middle, Last) Beeficiary Relatioship Percetage 13. Certificatio: I hereby request the group isurace coverage for which I am or may become eligible ad authorize deductios from my earigs to serve as paymet for ay required cotributios. I certify these aswers ad statemets are complete ad true to the best of my kowledge ad belief. I will iform Iteratioal Healthcare Solutios of ay chages i my or my family s health or of ay chage to the iformatio provided which take place betwee the time the form is completed ad the time coverage becomes effective. I agree that this documet shall form a part of my request for group coverage. Ackowledgemet: I uderstad that, to the extet permitted by statute or policy, false statemets or misrepresetatios i my applicatio or addedums may result i the deial of claims or i my isurace coverage beig void as of its effective date with o beefits payable. I uderstad that coditios which are disclosed o this form may be subject to all coditios of my employer s Pla icludig ay pre-existig coditio limitatios, employee actively at work ad depedat health coditio requiremets. My sigature idicates that I have reviewed all iformatio ad statemets o this form for completeess ad accuracy. Authorizatio: To all physicias ad other health professioals, hospitals ad other health care istitutios, isurers, medical, or hospital service ad prepaid health plas, ad employers: you are authorized to provide Iteratioal Healthcare Solutios ad/ or Geerali Worldwide ad affiliates iformatio cocerig health care, advice, treatmet or supplies (icludig those related to metal illess ad/or AIDS/ ARC/ HIV) provided me or ay members of my family for whom coverage has bee requested. This iformatio may be used for the purpose of determiig eligibility for coverage ad i the adjudicatio of future claims. I agree that a copy of this authorizatio is as valid as the origial. FRAUD WARNING NOTICE: Ay perso who, with the itet to defraud or kowig that he/she is facilitatig a fraud agaist a isurer, submits a health history questioaire or files a claim cotaiig a false or deceptive statemet is guilty of isurace fraud. 5 of 6 Geerali Worldwide Isurace Compay Limited Group Health Isurace Health Isurace Applicatio Form

6 Employee Sigature (Employee must sig at all times): Date: (MM/DD/YY) Spouse s Sigature (Spouse must sig whe spouse coverage is requested): Date: (MM/DD/YY) This completed ad siged form may be retured to: Iteratioal Healthcare Solutios Ltd., PO Box 10212, Grad Cayma KY1-1002, Cayma Islads, fax: or [email protected] SECTION C To be completed by Iteratioal Healthcare Solutios Effective Date: / 01 / By: Date: (MM/DD/YY) Office: Geerali Worldwide Isurace Compay Limited, Secod Floor, Bougaivillea Way, Grad Pavilio Commercial Ceter, 802 West Bay Road. Mailig address: Geerali Worldwide Isurace Compay Limited, PO Box 10212, Grad Cayma, KY1-1002, Cayma Islads. Regulated i the Cayma Islads as a licesed isurer by the Cayma Islads Moetary Authority. Icorporated i Guersey uder Compay Registratio No T F [email protected] geerali-worldwide.com Registered Head Office address: Geerali Worldwide Isurace Compay Limited, Geerali House, Hirzel Street, St Peter Port, Guersey, Chael Islads GY1 4PA. Head Office: Regulated i Guersey as a licesed Isurer by the Guersey Fiacial Services Commissio uder the Isurace Busiess (Bailiwick of Guersey) Law, 2002 (as ameded). Geerali Worldwide Isurace Compay Limited is part of the Geerali Group, listed i the Italia Isurace Group Register uder umber 026. Websites may make referece to products that are ot authorized or regulated ad/or are ot available for offerig to plaholders i certai jurisdictios. 6 of 6 Geerali Worldwide Isurace Compay Limited Group Health Isurace Health Isurace Applicatio Form