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Application for International Medical (Heath) Insurance

By filling out this application you are applying for insurance cover under International Medical (Health) Insurance. You may find the detailed description of general terms and conditions of this cover in the International Medical Insurance Terms and Conditions (the “Rules”). The Rules provide description of definitions used herein and throughout the Insurance Contract.

This application shall not constitute a binding offer for an insurance cover, since necessary assessment of risks to be insured (Underwriting), as well as confirmation of the date of entry into force of your insurance cover, must yet be executed for this purpose based on the information as provided herein and received otherwise.

Your insurance shall commence after you are explicitly accepted for cover and as of the starting date confirmed by the Insurer. Until then, you must inform the recipient of this application without delay about any new occurrences / circumstances, which would change your answers provided in this application. Any such changes may require new Underwriting of risks to be insured and result in changes of special insurance terms that may be offered to you. The Insurer reserves the right to alter such terms or decline your insurance cover.

Please complete this application in full (including putting signatures and dates wherever requested) in order to assure its fast and accurate processing. This application consists of the following: general part, Medical Questionnaire, the Privacy Notice and the Explicit Consent form. The application shall be deemed to be filled out fully only when all the parts thereto are duly filled out.

For handling of this application and later on (as the case may be) for execution and implementation of your insurance cover, your Personal Data (including some of your Sensitive Personal Data) will have to be processed. Therefore, please read the Privacy Notice carefully before filling in this application.

Medical Questionnaire makes up an inseparable part of this application. Your Sensitive Personal Data (as requested in the Medical Questionnaire and elsewhere in this application) is needed in order to evaluate the risks to be insured (Underwrite) and to be able to propose special terms for your desired cover (unless you chose an insurance coverage not requiring prior medical underwriting). Based on the General Data Protection Regulation (GDPR), your explicit consent is necessary to process your Sensitive Personal Data. The form of such consent is attached to this application. Consequences of your refusal to provide the said consent are explained in the Explicit Consent form.

You must answer all the questions fully, truthfully and accurately. Even if you have already provided your data before with any other application, you must present it again (whenever requested). Based on the data you provide herein, Underwriting and issue of a proposal for your insurance cover will be executed. Furthermore, this application will form a part of your insurance contract (if agreed upon and concluded).

When filling out this application, please make sure to write/type clearly using blue or black ink. This application must be filled out in respect of each person applying for coverage. Parents / guardians fill in for their children under 18 years old.

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- Name*
  First Middle Last
- Address*
  Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country
- Email*
  Enter Email Confirm Email
- Phone*
- Date of Birth*
  DD dot MM dot YYYY
- Gender*
- Marital Status*
- ID/Passport Number*
- Citizenship*
- Nationality*
Has your cover ever been arranged by DHIG before?*
- Yes
- No

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Employment details
- Name of Employer*
- Address of Employer*
  Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country
- Occupation / Job Title*
- Date of hire*
  DD dot MM dot YYYY
- Working hours / week
  Please enter a number from 0 to 40.
- Date of depature for international assignment
  DD dot MM dot YYYY
- Country of residence during assignment
- Anticipated return from international assignment
  DD dot MM dot YYYY

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Dependants
Do you also want cover for your…
- Spouse
- Child(ren)
- Name of Spouse*
  First Middle Last
- Date of Birth of Spouse*
  DD dot MM dot YYYY
- Country of residence of Spouse*
- Name of Child 1*
  First Middle Last
- Date of Birth of Child 1*
  DD dot MM dot YYYY
- Country of residence of Child 1*
- Name of Child 2*
  First Middle Last
- Date of Birth of Child 2*
  DD dot MM dot YYYY
- Country of residence of Child 2*
- Name of Child 3*
  First Middle Last
- Date of Birth of Child 3*
  DD dot MM dot YYYY
- Country of residence of Child 3*
- Name of Child 4*
  First Middle Last
- Date of Birth of Child 4*
  DD dot MM dot YYYY
- Country of residence of Child 4*

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Employment details

Dependants

Coverage Details