Application form - Health Insurance Program

Family Name :

First Name :

Effective date of coverage must be on the 1st of each month : / /

SWISS GLOBAL INSURANCE Plan :DIAMONDPLATINUMCLASSICESSENTIAL

Zone of coverage :Zone A: worldwide coverage including USA & Canada, excluding Switzerland. Premiums in USDZone B: worldwide coverage excluding USA & Canada, including Switzerland. Premiums in CHFZone C: worldwide coverage excluding USA, Canada, Switzerland. Premiums in EUR

APPLICANT DETAILS:

Gender :M.F.

Date of Birth : / /

Nationality :

Family status :SingleMarriedDivorcedOther Occupation

Occupation :

Are you (or your spouse) eligible for benefits from any Social Security or government plan reimbursement, or do you have any
other group medical insurance in force today ? YesNo

If Yes, please describe :

Country of your Social Security plan :

Social Security ID Number(s) :

SPOUSE (or Partner) and dependent CHILDREN to be covered:

If you have dependent children aged more than 21, please join to this form a certificate of attendance at school or university

Familiy Name
First Name
Date of Birth
Gender (M or F) / Spouse/Child (S or P)

/ /

+ Add person

Applicant's mailing addres

Address in country of expatriation:

Street :

City :

Postal code :

Country :

Phone number :

E-mail :

Address in home country:

Street :

City :

Postal code :

Country :

Phone number :

Payment of premiums:

Payment frequency :QuarterlyHalf - YearlyYearly

Would you like to do your payment by :Credit cardBank Transfer

Reimbursements of claims

Currency of your bank account :

Account Beneficiary Name :

For bank-to-bank transfers, please complete the following and attach a deposit slip

Account N° :

Name of Bank :

IBAN :

BIC – €, ABA – US$) :

Address of Bank:

Street :

City :

Postal / ZIP Code :

Country :

Confidential Medical Questionaire

Have you, or any person named in page 1 been treated for, or have had a history of:

(Please tick if Yes)

Applicant

FRAUD NOTICE

Any person who (1) dishonestly files an application for insurance or a claim under a policy containing information he knows to be untrue or misleading; or who (2) in making an application for insurance or claim under a policy dishonestly fails to disclose information which has beenasked for, may commit fraud.
We will investigate any claims or applications for insurance which we have grounds to believe may be fraudulent. Committing fraud may result in your policy being terminated and any claims you make under not being paid.
We may, for the purposes of the detection and prevention of fraud, share information relating to suspected fraud with other insurance companies and/or with law enforcement authorities.

Statement

I hereby certify that the foregoing declarations are accurate, complete and fair and have been correctly written to the best of my knowledge and belief.
I have been informed and I accept that any intentional withholding of significant information or false declaration by me or on my behalf may lead to the cancellation of the insurance cover.
I may examine and correct any personal information in the files maintained by SWISS GLOBAL INSURANCE on my behalf. For underwriting and claim purposes, I hereby authorize any physician who has examined me to transmit medical data to the physician of the Insurer and/or its Plan Administrator.
I accept these terms and conditions and I wish to be covered by this policy.

Please send us a copy of your passport: