healthpoint Application

Application for International Medical (Heath) Insurance

By filling out this application you are applying for an International Medical (Health) Insurance. You may find the detailed description of general terms and conditions of this cover in the International Medical Insurance Policy (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. 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).

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.

Please read the Privacy Documentation carefully before deciding on providing us with your explicit consent to processing of your Sensitive Personal Data.

For the purpose of this consent:

• The Insurance Contract means the Insurance Certificate to be issued as a confirmation of insurance being in force, as well as the Insurance Policy (terms and conditions) adopted by the Insurer for this insurance, and all questionnaires and consents completed by the Insured Person and/or Policyholder.
• The Policyholder means a capable adult the entity, entering into the Insurance Contract and paying the insurance premium. Natural persons residing in Bermuda can not become Policyholders under this insurance.
• Insured Person means a natural person for the benefit of whom the Policyholder entered into the Insurance Contract. When a natural person enters into an Insurance Contract for own benefit, he/she acquires the rights and obligations of the Policyholder and those of the Insured Person.
• The Insurer means your insurer under the Insurance Policy.

Your explicit consent is required for us to be able to collect, store and use your Sensitive Personal Data for assessing and handling your filed Form and related claims.  Sensitive Personal Data means Personal Data that can reveal a data subject’s racial or ethnic origin, political opinions, religious or philosophical beliefs or trade union membership; it also refers to the processing of data concerning data subject’s health, sexual orientation or sex life.

Please note that:

• you are not obliged to provide this consent,
• you are entitled to withdraw any your provided consent for processing of your Personal Data (including Sensitive Personal Data) at any time as foreseen in the Privacy Documentation.

However, if you do not provide your explicit consent for processing of your Sensitive Personal Data or withdraw it, the Insurer will not be able to assess and handle the Form and your related claim.