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- Download healthcare insurance application form

- Download healthcare insurance application form for family

CLIENT DETAILS
POLICYHOLDER NAME:
Enter the policy holder name
Billing Address:
Please enter your address.
Tel:
Input Valid formats:
Email:
Enter the policy holder email
PLAN DETAILS
FOUNDATION SERIES

VND 500,000,000

VND 1,000,000,000

VND 2,000,000,000
OPTIONAL OUTPATIENT
(Client can choose any plan)
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OPTIONAL BENEFITS
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MASTER SERIES

VND 5,000,000,000

Upgrade Benefits
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VND 10,000,000,000

VND 20,000,000,000
OPTIONAL BENEFITS
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Personal Accident:
Invalid Input Unit = VND 200,000,000 Sum Insured from 1 billion VND to 10 billion VND Amount of PA selected:


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DISCOUNT
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SENIOR SERIES

VND 1,500,000,000

VND 2,000,000,000

VND 5,000,000,000
OPTIONAL BENEFITS
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Personal Accident:
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Unit = VND 200,000,000 Sum Insured from 1 billion VND to 10 billion VND Amount of PA selected:
DISCOUNT
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GROUP DISCOUNT PREMIUM PAYMENT POLICY EFFECTIVE DATE
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INSURED NAME (last/middle/first):
enter family name
Tel:
Input Valid formats: (No space for phone number)
Email:
Enter insured person's email
Relationship to Policyholder
Select the relationship
Height(cm):
Enter the height in centimetre
Weight(kg):
Enter your weight in Kg
Occupation:
Enter your occupation and job title
Date of Birth (dd/mm/yy):
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Gender:
Select the gender
Smoker:
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Passport / ID #:
Enter the Passport/Government ID Number
Country of Residence:
Select a Country of Residence
Country of Citizenship:
Select the Country of Passport
BENEFICIARY INFORMATION (for Personal Accident Benefit only)
Beneficiary Designation:
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Relationship:
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MEDICAL QUESTIONAIRE

Please answer the questions below (if Insured person is under 18 years old, parents are required to complete and sign on behalf of children). All information provided is kept in the strictest confidentiality. Your complete and accurate responses will assist us to properly underwrite your policy.
YES NO
1.
a.Are you currently covered by a medical policy? (if YES, please provide a copy of the policy and benefit schedule)
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b.Have you had any medical insurance application or policy declined, rated, restricted, or cancelled, at any time in the past? IF YES, please state the reason:
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2.Have you ever had symptoms of or been diagnosed with, investigated or treated for any of the following:
a.Psychological or psychiatric conditions, drug and alcohol issues or sleep disorders?
Ex: depression, anxiety, stress, autism, insomnia, sleep apnea, drugs and alcohol dependency, etc.
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b.Heart or circulatory conditions?
Ex: high/low blood pressure, angina/chest pains, heart attacks or heart failure, coronary arteries, ischemia, deep veins thrombosis, varicose vein, etc.
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c.Tumors, growths or cancer?
Ex: polyps, benign growths or cysts, lymphomas, any cancers or pre-cancerous conditions, etc.
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d.Brain or nervous system conditions?
Ex: stroke/transient ischemic attack (TIA), syncope, seizure or epilepsy, migraines, multiple sclerosis, meningitis, neuritis, etc.
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e.Diabetes, thyroid, metabolic or any other endocrine disorders?
Ex: diabetes type 1 or type 2, hypothyroidism or hyperthyroidism, dyslipidemia, pituitary or adrenal problems, etc.
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3.In the last 5 years, have you seen a physician, or experienced any symptoms, or been admitted to a hospital, or medical facility for an operation or procedure, or undergone any tests or investigations, for any of the following conditions?
a. Eyes, ears, nose or throat?
Ex: glaucoma, cataracts, retinal detachment, macular degeneration, hearing difficulties/loss, relapsed otitis, tonsillitis, sinusitis, etc.
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b.Breathing or respiratory conditions?
Ex: asthma, chronic obstructive pulmonary disease (COPD), emphysema, shortness of breath, pneumonia, bronchitis, tuberculosis (TB), all kind of respiratory allergies, etc.
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c.Urinary, kidney, ureter, bladder, urethral or prostate conditions or STI?
Ex: kidney, bladder, urethra infections or stones, prostate problems, sexually transmitted infections, etc.
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d.Stomach, liver, gall-bladder, pancreas, or digestive system conditions?
Ex: gastritis, gastroesophageal reflux disease (GERD), hepatitis, cirrhosis, gallstones, pancreatitis, irritable bowels, colitis, hemorrhoids/piles, persistent diarrhea, Crohn’s disease, digestive ulcers, abdominal pain, bleeding, all kind of hernia, etc.
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e.Neck, back, joint, muscular or skeletal problems?
Ex: neck, back or joint pain, sciatica, arthritis, osteoarthritis of spine, gout, joint replacements, fracture, cartilage or ligament problems, etc.
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f.Auto-immune disorders?
Ex: HIV/AIDS, rheumatoid arthritis, systemic lupus erythematosus, scleroderma, etc.
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g.Skin conditions?
Ex: eczema, dermatitis, rashes, psoriasis, acne, moles that itch or bleed, or all kind of skin allergic reactions, etc.
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h.Gynecological or breast conditions?
Ex: irregular periods, fibroids, prolapse, endometriosis, abnormal Pap test, cervix, uterus, ovaries or fallopian tube disorders, etc.
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i.Any physical defect or congenital condition?
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4.Have you been advised to undergo or have you undergone any medical test, medical check-up, taken medication, or had a procedure not mentioned above?
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5.I would like to see if my conditions can be covered (additional medical information may be required)
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  When you answered “YES” to any of the questions above, please use the space below to provide the necessary detail.
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DECLARATION
I hereby declare that all information above, including all papers and documents, which were submitted according to the requirements of this Healthcare Insurance Application, are true, accurate and complete. I understand that untruthful information, concealment, or misrepresentation of any significant condition will result in the voiding of all applicable insured’s benefits under the plan. I further understand that the premium is based on the insured person residency in Vietnam. I do hereby authorize any licensed physician, medical practitioner, hospital, clinic, or other medical or medically related facility, insurance company or other organization, institution or person, that has any records or knowledge of me or my health, to give to Pacific Cross Vietnam any such information. A photographic copy of this authorization shall be valid as the original..
Applicant Name
Enter your name
Broker Name or Number (if applicable)
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