Joining General Hospitals Your application
i m p o rta n t i n f o r m at I O N Please write clearly in black ink and BLOCK CAPITALS. Return this form to your company’s General Hospitals Group Secretary in a sealed envelope. If you have any questions when completing this form, please call us on ----------------------
Checklist -
please make sure:
We will not be able to process your application if this form is incomplete.
you have read, signed and dated the declaration in section 6
Please be sure to check the entire form.
the information you have given in sections 1-6 is correct and complete
Code
1
Main member: your personal details
Title
First name / Company
Other initials
Family name
Male / Female
Nationality
1st Language
ID or Passport Number Occupation
D
D
M
M
Y
Yes No
Insured
2
Date of birth
Main member: your address details (please let us know straightaway about any change of address)
Residency address (your permanent or usual address in the country where you are resident. This should be the country in which you are living on the first day of your current membership year.)
Correspondence address (where membership documents cannot easily be sent to you at your residency address, please supply an alternative address to which they may be sent)
Building name / number
Building name / number
Street
Street
Town/City
Town/City
Postal / zip / area code
Postal / zip / area code
Region
Region
Country
Country
3
Main member: your other contact details
Main contact (home) Country code
Secondary contact (work) Area code
Number
Country code
Telephone
Telephone
Fax
Fax
Mobile
Mobile
Area code
Number
Y
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Follow these icons when referring to yourself and additional persons
= Main member 1
= First additional person
2
= Second additional person
3
2
= Third additional person
3rd
Additional persons to be covered with you
4
1st additional person
Title Other initials Male / Female
4th
First name
1
Family name Nationality
1st Language
Occupation
Date of birth
This
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Title Other initials Male / Female Occupation
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Relationship to you
If any of these additional persons have different home or correspondence addresses to yours, please write their name and addresses on a separate sheet and confirm you have done so by ticking here:
D
5
Personal and medical history
1. What is your height and weight?
2. Are you or have you been smoker?
2nd Additional Person
Main Member .........................cm.
.........................cm.
.........................cm.
.........................cm.
.........................kg.
.........................kg.
.........................kg.
.........................kg.
Yes
No
Yes
No
Yes
No
Yes
No
Yes
No
Yes
No
Yes
No
Yes
No
Yes
No
Yes
No
Yes
No
Yes
No
If yes, specify when and daily allowance. Do you consume or have consumed alcohol or drugs? If yes, specify the amount and type of day beverage / product
If so, indicate which, duration and results. 3.
If you have nearsightedness or farsightedness or astigmatism, indicate eye dioptre or those previously to a refractive surgery in such a case.
4. Has followed, is or has been prescribed some type of medical or surgical treatment? (pharmacological,
..................diopters
..................diopters
..................diopters
..................diopters
Yes
No
Yes
No
Yes
No
Yes
No
Yes
No
Yes
No
Yes
No
Yes
No
Yes
No
Yes
No
Yes
No
Yes
No
Yes
No
Yes
No
Yes
No
Sí
No
If so, indicate which and results.
5. Do you suffer some congenital and/or hereditary anomaly or functional defect? If so, indicate which and if it physically or mentally invalidates you. 6. Have you had or have any of the following diseases? Acute myocardial infarction, angina pectoris, embolism, rheumatic problems, chronic bronchitis, sleep apnea, Crohn, ulcerative colitis, psychosis, eating disorders, neurological degenerative, dementia, HIV carrier, carrier of hepatitis C, diabetes, disorders of coagulation. If yes, indicate which, when and duration
7. Have had or have any of the following diseases? Cardiovascular (hypertension, thrombosis, varicose veins) joint) Respiratory (asthma), (haemorrhoids, fistulas, liver disease), psychiatric (anxiety, depression), Neurological (epilepsy), Tropical), metabolic or blood (increased cholesterol, uric acid, thyroid disease, Malignant hormonal disorders, anemia), or benign tumor genitourinary prostate, ovary, womb, kidney disorders), skin (psoriasis, skin cancer, allergic,) If so, or if you have suffered or are suffering
1
you have ticked NO on “Insured”, then do not fill in the column “Main Member”
6
Your membership declaration
In view of the declaration below, it is essential that complete information is supplied. Benefits may not be payable if you do not fully disclose any material facts which could influence our assessment and acceptance of this application and, if you are in any doubt as to whether any facts are material, you should disclose them. You are advised to keep a record of all information you supply to us in connection with this application, including letters. If you would like a copy of this application form, please ask us. It is General Hospital’s intention to provide a first class service to our members at all times. However, if you have any comments or complaints, you can call the General Hospitals customer helpline on -----------------------, 24 hours a day, 365 days a year. Alternatively you can email via www.-------------, or write to us at: General Hospitals,-------------------------------------------------------------------------. If we have not been able to resolve the problem and you wish to take your complaint further, please call General Hospitals customer helpline on -------------------------, or write to our head of Customer Relations a the above address. For hearing or speech impaired members with a textphone, -------------------------- Please let us know which you would prefer. English Law shall apply to the agreement between you a General Hospitals. I hereby apply to be enrolled as a Member with the Dependants listed above included in my membership. I declare that to the best of my knowledge and belief the information given in this Application is true and complete. I agree that the Rules of the General Hospitals scheme will be binding on me and all eligible Dependants included in my membership. I confirm that I give explicit consent, within the provisions of the Data Protection Act 1998, on behalf of myself and any family members specified in this form for General Hospitals to process our persona l information with respect to our membership and I confirm that I have brought the Data Protection Notice to the attention of these family members.
General Hospitals Data Protection Notice Purpose: Personal data collected on you, and where appropriate, your family, will be used by General Hospitals to process your claims, administer your policy and may be used to detect and prevent fraud or improper claims. The confidentiality of patient and member information is of paramount concern to General Hospitals. To this end, General Hospitals fully comply with UK Data Protection Legislation and Medical Confidentiality Guidelines. Medical Information: Medical information will be kept confidential. It will only be disclosed to those involved with your treatment or care, including your General Practitioner/Primary Health Physician, or to their agents, and, if applicable, to any person or organisation who may be responsible for meeting your treatment expenses, or their agents. Claims information may also be shared with appointed third parties involved in the management and handling of your claim. Claims information may be discussed with the General Hospitals Agent/Adviser where you have requested the Adviser to assist you. Member details: All membership documents and confirmation of how we have dealt with any claim you may make will be sent to the principal member. Telephone calls: In the interest of continuously improving our service to members, your call will be recorded and may be monitored. Research: Anonymised or aggregated data may be used by General Hospitals, or disclosed to others, for research or statistical purposes. Fraud: Information may be disclosed to others with a view to preventing fraudulent or improper claims. Names and Addresses: General Hospitals does not make the names and addresses of members or patients available to other organisations. Keeping you informed: General Hospitals would, on occasion, like to keep you informed of Genral Hospitals products and services which it considers may be of interest to you. Contact Address: If you do not wish to receive information about General Hospital’s products and services, or have any other Data Protection queries please write to the General Hospitals Group Information Protection Manager.
i m p o rTa n T i n f o r m aT i o n - Yo U r m E m B E r S H i p D E C L a r aT i o n Please be aware that this form must be received by General Hospital no more than six weeks after the declaration date.
If we receive this form after six weeks from this declaration date, or with incomplete information, we will be unable to register your details and enrol you on the plan.
It is advisable that you fill in your form with complete up-to-date medical history before you sign and date this form.
Signature
Date
______________________________________________ , _________ of _________________ 20___
Main Member Name and Surname __________________________ Signature
1st Additional Person Name and Surname __________________________ Signature*
IN-FORM-CAF-09v2
* Only if you are on the age of majority (Otherwise, signature of the legal guardian)
2nd Additional Person Name and Surname __________________________ Signature*
3r d Additional Person Name and Surname __________________________ Signature*