Health Insurance Application Form

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Client Details

Policyholder name:

Enter the policy holder name

Billing Address:

Vui lòng nhập đầy đủ thông tin

Tel:

Contact Email:

Enter the policy holder email

A - INSURED PERSON DETAILS

Full Name (last/ middle/ first):

enter family name

Relationship to Policyholder:

Select the relationship

Height (cm):

Enter the height in centimetre

Weight (Kg):

Enter your weight in Kg

Date of birth (dd/mm/yy):

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Gender:

Select the gender

Occupation:

Enter your occupation and job title

Work description (Ex: office/administration, retail/trading duties, light manual labour, etc.):

Passport/ ID #:

Enter the Passport/Government ID Number

Country of Residence:

Select a Country of Residence

Country of Citizenship:

Select the Country of Passport

Do you currently smoke or use tobacco product?

Invalid Input

If you have quit smoking, please state when (mm/yy):

Tel:

Input Valid formats:

Contact Email:

Nhập thư điện tử liên hệ

I hereby authorize Pacific Cross Vietnam to communicate with me via my email address. I further accept email communications form part of my policy

For Insured Person under age 03:

In which week of pregnancy was this child born?

weeks. Height and weight at birth:

Kg.

Does this child have twin/triplet brother(s) and/or sister(s)?

B-PLAN SELECTION

FOUNDATION	STANDARD – VND 500,000,000	EXECUTIVE – VND 1,000,000,000
In-patient
Out-patient
Additional Benefit	Dental 1	Dental 2

Master	M1+ -VND 5,000,000,000	M2 - VND 10,000,000,000	M3 - VND 20,000,000,000
Additional Benefit	VND 1,000,000,000 Surgeon's Fee Upgrade (for M1+ only)
Additional Benefit	Dental LifeStyle 1 LifeStyle 2 Pesonal Accident Amount Invalid Input
Discount Options	Treatment Area Limit (25%) Outpatient Exclusion (30%)
Discount Options	20% Co-payment (25%) VND 50,000,000 Inpatient Benefits Deductible (20%)

Beneficiary information: (for Personal Accident Benefit only)

Beneficiary Designation:

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Relationship to Insured Person:

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Payment option:

AnnualSemi-Annual (surcharge is applied)Please select payment option

Preferred Coverage effective date (dd/mm/yy):

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D-SUPPLEMENT

If you answered “YES” to any of the above questions 2, 3, 4 in Part C, please give complete details including medical history, diagnosis, nature/date of care and treatment received, date of last consultation, related medical reports, name and contact details of your personal physician or doctor, etc.

E-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.

Name of Insured person:

Enter your name

Broker:

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Date (dd/mm/yy):

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1. - Are you currently covered by a medical policy? (if YES, please provide a copy of the policy and benefit schedule)	YesNo
- 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:	YesNo
2. Have you ever had symptoms of or been diagnosed with, investigated or treated for any of the following:
2.1. Psychological or psychiatric conditions, drug and alcohol issues or sleep disorders? Ex: depression, anxiety, stress, autism, insomnia, sleep apnea, drugs and alcohol dependency, etc.	YesNo
2.2. 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.	YesNo
2.3. Tumors, growths or cancer? Ex: polyps, benign growths or cysts, lymphomas, any cancers or pre-cancerous conditions, etc.	YesNo
2.4. Brain or nervous system conditions? Ex: stroke/transient ischemic attack (TIA), syncope, seizure or epilepsy, migraines, multiple sclerosis, meningitis, neuritis, etc.	YesNo
2.5. Diabetes, thyroid, metabolic or any other endocrine disorders? Ex: diabetes type 1 or type 2, hypothyroidism or hyperthyroidism, dyslipidemia, pituitary or adrenal problems, etc.	YesNo
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?
3.1. Eyes, ears, nose or throat? Ex: glaucoma, cataracts, retinal detachment, macular degeneration, hearing difficulties/loss, relapsed otitis, tonsillitis, sinusitis, etc.	YesNo
3.2. 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.	YesNo
3.3. Urinary, kidney, ureter, bladder, urethral or prostate conditions or STI? Ex: kidney, bladder, urethra infections or stones, prostate problems, sexually transmitted infections, etc.	YesNo
3.4. 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.	YesNo
3.5. 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.	YesNo
3.6. Auto-immune disorders? Ex: HIV/AIDS, rheumatoid arthritis, systemic lupus erythematosus, scleroderma, etc.	YesNo
3.7. Skin conditions? Ex: eczema, dermatitis, rashes, psoriasis, acne, moles that itch or bleed, or all kind of skin allergic reactions, etc.	YesNo
3.8. Gynecological or breast conditions? Ex: irregular periods, fibroids, prolapse, endometriosis, abnormal Pap test, cervix, uterus, ovaries or fallopian tube disorders, etc.	YesNo
3.9. Any physical defect or congenital condition?	YesNo
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?	YesNo
I would like to see if my conditions can be covered (additional medical information may be required)