Health Insurance Application Form For Group

CUSTOMER INFORMATION

Policyholder name (*)

Billing Address: (*)

Tel: (*)

Contact Email: (*)

A - INSURED PERSON DETAILS

	Insured Person 1	Insured Person 2	Insured Person 3	Insured Person 4
Full Name (last/ middle/ first)
Relationship to Policyholder
Height and Weight
Date of birth (dd/mm/yy)
Gender
Occupation
Work description (Ex: office/ administration, retail/ trading duties/ light manual labour, etc.)
Passport/ ID #
Country of Residence
Country of Citizenship
Do you currently smoke or use tobacco product?	Yes No	Yes No	Yes No	Yes No
If you have quit smoking, please state when (mm/yy):
Tel
Email
	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?
Height and Weight at birth
Does this child have twin/triplet brother(s) or/and sister(s)?	Yes No	Yes No	Yes No	Yes No

B-PLAN SELECTION

CHOOSE PRODUCT

	Insured Person 1		Insured Person 2		Insured Person 3		Insured Person 4
HEALTH FIRST	core_benefit	OUTPATIENT	core_benefit	OUTPATIENT	core_benefit	OUTPATIENT	core_benefit	OUTPATIENT
HF1 - 150.000.000 VNĐ
HF2 - 250.000.000 VNĐ
HF3 - 450.000.000 VNĐ
DENTAL	HF1 HF2 HF3		HF1 HF2 HF3		HF1 HF2 HF3		HF1 HF2 HF3
PERSONAL ACCIDENT

	Insured Person 1		Insured Person 2		Insured Person 3		Insured Person 4
HEALTHUP	core_benefit	OUTPATIENT	core_benefit	OUTPATIENT	core_benefit	OUTPATIENT	core_benefit	OUTPATIENT
HU1
HU2
DENTAL	HU1 HU2		HU1 HU2		HU1 HU2		HU1 HU2
PERSONAL ACCIDENT