healtpoint Application Signature
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).
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.
My work includes:
Height: Weight: BMI:
Smoking habit: Drinking habit:
I am aware that, according to my insurance contract to be concluded in accordance with the International Medical Insurance Policy, the Extreme Sports, Chronic diseases and Pre-Existing Medical Conditions shall NOT be covered. Also I am aware that 11-month Waiting Period shall apply in respect of an Oncological Disease even if first diagnosed after the Insurance Start Date.
One of my natural parents, brothers or sisters, before their 50th birthday, been diagnosed with cardiovascular disease (heart attack, bypass surgery or stroke), polycystic kidney disease, or cancer of the bowel, breast, colon, ovarian, prostate, melanoma, pancreas or kidney?
Have you had or been recommended to have, or are you currently on a waiting list for an organ transplant?
Do you currently or did you suffer during the last 6 months from any persisting or recurrent symptoms and/or signs which have not yet been investigated?This includes any lump in the breast or in testicles, rectal bleeding, blood in urine, unusual cough longer than six weeks, jaundice, unexplained weight loss, headaches of increasing frequency, vision disturbances (blurry/double vision, unexplained vision loss), unexplained hearing loss, speech difficulties, weakness of limbs, seizures, fits or fainting and abnormal lab values of your blood check in relation to blood count, creatinine, liver enzymes, calcium levels or tumour markers.
At any time in the last 10 years have you been diagnosed or received treatment of any kind in connection with any of the following illnesses?
Your answer: None of the above
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 Policy means the Insurance Policy you will be covered underThe Policyholder means the entity, which arranged your insurance cover and which is indicated in the Insurance Policy as the Policyholder;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</strong> 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.
I hereby agree that in the course of implementation of the Insurance Policy providing my insurance cover, the Policyholder shares with the Insurer such Personal Data as is necessary for implementation of this Policy or as is obligatory in accordance with applicable laws.
The Insurer may collect, store and use my Personal Data, including Sensitive Personal Data, for assessing and handling the Form and my related claim.
In respect of the Form, I hereby waive my rights to confidentiality / secrecy of my Sensitive Personal Data and authorize my general practitioner, other relevant medical professionals and establishments (e.g. doctors, physicians, therapist, hospitals and other medical establishments (their stuff)), to provide my medical records, health details and other my Personal Data if requested by the Insurer, its authorised medical advisers or representatives (including the company dhig GmbH). Please note that should you refuse to authorize your general practitioner, other relevant medical professionals and establishments to share your Personal Data with the Insurer, you shall be liable to present all such data to the Insurer yourself.
Requested Insurance Start Date:
Date of Signature:
Please upload a copy of a goverment issued ID: Text
I am not a sanctioned person under EU and US regulations. I confirm I don't confirm
I am not a polotical exposed person (PEP). I confirm I don't confirm
Leave this empty:
Your legal name
Your email address
Signed by daily health insurance group dhig
Signed On: 27/01/2021
If you have questions about the contents of this document, you can email the document owner.
Document Name: healtpoint Application Signature
Agree & Sign