Insurance Expat Application

INSURANCE EXPAT APPLICATION

Applicant / Insured Information

Expat Assignment Details

Requested Policy & Coverage Details

Coverage Options & Limits

Please indicate which optional coverages you require. Selected coverages will be subject to underwriting approval and endorsement.

Exclusions (Representative)

The insurer will not provide cover for loss, expense, liability or treatment arising directly or indirectly from: (a) war, invasion, hostilities, civil unrest or terrorist acts where a government advisory against travel to the location has been issued; (b) deliberate self-injury, suicide or attempted suicide; (c) participation in professional or extreme sports, hazardous activities or criminal acts not declared and accepted in writing by the insurer; (d) nuclear, biological or chemical contamination; (e) routine dental treatment except where specified; (f) treatment for conditions arising from alcohol or substance abuse; (g) expenses resulting from a pre-existing condition that has not been disclosed and accepted in writing; and (h) known conditions for which medical care has been arranged prior to the effective date. Additional exclusions may apply as set forth in the policy document and any endorsed amendments.

Medical History & Declarations

You must answer the following truthfully. Failure to disclose material medical facts may result in denial of coverage or rescission of the policy.

Beneficiary Designation

Designate primary and secondary beneficiaries for any life/accidental death benefits. Percentages must total 100% for primary and secondary combined.

Declarations, Authorisations & Acknowledgements

I declare that the statements and answers given in this application are true, complete and correctly recorded. I understand that this application and any information supplied in support shall form the basis of any policy issued. I acknowledge that failure to disclose material facts or any wilful misrepresentation may render the policy void and may prejudice any entitlement to benefit.

I authorize any physician, hospital, medical facility or insurer to provide medical or claims information to the insurer for the purposes of underwriting and claims handling. I understand that coverage is subject to underwriting approval and payment of the required premium. I further agree that any policy issued will be subject to the terms, conditions, limitations and exclusions contained in the policy document.

I consent to the insurer using and disclosing personal data as reasonably required for underwriting, policy administration and claims handling. Where required by law, I consent to the transfer of such information to affiliates and third-party service providers in jurisdictions outside my country of residence.

I acknowledge receipt of the privacy notice and understand that compliance with anti-fraud provisions is a condition of coverage. I further confirm that I have read and accept the exclusions and limitations set forth in this application.

Agent / Broker (if applicable)

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