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Health Insurance Application Form

Thank you for applying for our high quality, cost effective health insurance plans. Your Security is of the utmost importance. Therefore, the data you enter below is sent directly to a real person and not to any database. Your data is totally secure and will NEVER be shared nor exported. Each application form is individually reviewed by an experienced approver who you may speak with directly in English. You will receive an email confirmation upon submission of this application form.


IMPORTANT! If you need proof of Health Insurance for a visa or residencypermit, be sure that the start date and end of coverage period you select, meet or exceed the full term and length of your visa or residency permit.

Starting Date of Insurance :Be sure this date matches your visa date
Insured's Date-of-Birth:.
Primary Insured's Gender:
Are you a student?:
Marital Status:
First Name:
Last name:
Mobile Number with country code:
Occupation:
Passport Number:
Date of Departure from home country:
Date of Departure from home country:
What is your Height (in/cm)?
What is your Weight (kg/lbs)?
Residence Address
Street & Number:
City/Municipality:
State/Region
ZIP/Postal Code:
Country:
Telephone Number:
Home Country Address or Billing Address
Street & Number:
City/Municipality:
State/Region
ZIP/Postal Code:
Country:
Telephone Number:
Expected residency and travel itinerary for the next year

Travel and Foreign Residency Dates and Destinations

Will you visit The United States, Canada, China, Hong Kong, Japan, Macau, Singapore or Taiwan during the policy period?
You must Purchase Gold Exclusive to extend coverage to this Countries. Be sure to carefully enter your destination(s) and Travel Dates. Thank You
Do you have a U.S Green Card or U.S Visa?
Please provide all tentative and planed travel destinations for the next 12 months with approximate departure, transit and return dates
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Medical Questionnaire

Please note before answering this important questionnaire, that all pre-existing conditions are excluded on all of our health plans. Failure to answer honestly may result in denial of medical claims. However, we will cover you and any family member applying (subject to our Terms and Conditions) for any and all non pre-existing conditions and approve you even if you have pre-existing  Conditions.

Ques. 1Are you, or any family member applying currently being treated for any medical issues or have operations been recommended to you, or any family member applying, or are you, or any family member applying currently intending to undergo any procedures?
Ques. 2Have you, or any family member applying been hospitalized, examined or treated in outpatient care, or suffered a serious injury in the past?
Please provide us with the diagnosis with dates and types of treatment prescribed.
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Please provide us with the diagnosis with dates and types of treatment prescribed.
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Ques. 3Do you, or any family member applying regularly take any medication(s)?
Ques. 4Have you, or any family member applying been examined or treated for (or been in contact with) tuberculosis, hepatitis (jaundice), AIDS, sexually transmitted diseases or any other infectious diseases?
Please provide us with the diagnosis with dates and types of treatment prescribed.
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Please provide us with the diagnosis with dates and types of treatment prescribed.
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Ques. 5Do you, or any family member applying consume alcohol in excess of 0.5L daily or any other addictive substances? (Alcohol and substance abuse treatment are not covered on the Gold Worldwide Plan)
Ques. 6Do you, or any family member applying smoke?
Please provide us with the diagnosis with dates and types of treatment prescribed.
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Please provide us with the diagnosis with dates and types of treatment prescribed.
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Ques. 7Have you, or any family member applying been diagnosed with any disorder of the following: Heart or blood vessels (e.g. high blood pressure, heart disease, stroke, pulmonary embolism, heart rhythm disturbances, phlebitis or chronic hemorrhoids, respiratory system (e.g. bronchial asthma, chronic respiratory disorders), digestive system (including disorders of the liver, gall bladder or pancreas), uric or reproductive system (e.g. infection, urinary stones, prostate disorders, gynecological disorders), nervous system (e.g. headaches, epilepsy, multiple sclerosis), musculoskeletal system (e.g. back pain, joint problems), metabolic (e.g. diabetes, thyroid gland, fat metabolism disorder), blood or immunity, tumors, mental, hernia, eye defect, cataract, glaucoma, hearing defect or skin disorder or suffer from any allergies?
Please provide us with the diagnosis with dates and types of treatment prescribed.
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Ques. 8Are you, or any family member applying a professional athlete?
Ques. 9Are you, or any family member applying pregnant?
Please provide us with the diagnosis with dates and types of treatment prescribed.
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Please provide us with the diagnosis with dates and types of treatment prescribed.
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I hereby confirm and agree that all of the requirements contained herein are true and accurate and have been entered in a precise and complete manner and that information was also provided to me in a clear, precise and complete manner, and that the meaning of the insurance terms and conditions was explained to me to a sufficient degree. I also agree to the processing of my personal and sensitive data and consent to the determination of my state of health by authorizing all doctors, hospitals, medical facilities and health insurers to provide requested medical records upon written request. I, nor any of my insured dependents reside in the US for more than 180 days within a 12 month period.

I agree that this application for private health insurance does not conflict with any obligations I may have under the state public health insurance laws nor does mandatory or voluntary enrollment in any public health insurance terminate this contract.

Digital Signature:

To satisfy ALL legal requirements in ALL jurisdictions, you are hear by required to scan or digitally photograph the photo/signature page(s) of your current and valid passport below. This scanned and sent photo/signature page of your passport will serve as your signature that confirms that all information and representations that you have provided above are true.Furthermore, this scan will also serve as your signature and full acceptance of all Terms and Conditions stated in the insurance contract that you have selected

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If you have any special requests, instructions or comments for us please enter them here
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