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

	Insured Person 1		Insured Person 2		Insured Person 3		Insured Person 4
FOUNDATION	Inpatient	Outpatient	Inpatient	Outpatient	Inpatient	Outpatient	Inpatient	Outpatient
Standard - VND 500,000,000
Executive - VND 1,000,000,000
Premier - VND 2,000,000,000
Premier - VND 2,000,000,000	Dental 1 Dental 2		Dental 1 Dental 2		Dental 1 Dental 2		Dental 1 Dental 2

MASTER	Insured Person 1	Insured Person 2	Insured Person 3	Insured Person 4
M1+ - 5.000.000.000 VNĐ
M2 - 10.000.000.000 VNĐ
M3 - 20.000.000.000 VNĐ
Additional Benefit	Dental LifeStyle 1 LifeStyle 2 VND 1,000,000,000 Surgeon's Fee Upgrade (for M1+ only) Personal Accident (PA)	Dental LifeStyle 1 LifeStyle 2 VND 1,000,000,000 Surgeon's Fee Upgrade (for M1+ only) Personal Accident (PA)	Dental LifeStyle 1 LifeStyle 2 VND 1,000,000,000 Surgeon's Fee Upgrade (for M1+ only) Personal Accident (PA)	Dental LifeStyle 1 LifeStyle 2 VND 1,000,000,000 Surgeon's Fee Upgrade (for M1+ only) Personal Accident (PA)

Discount Option:	Insured Person 1	Insured Person 2	Insured Person 3	Insured Person 4
Treatment Area Limit (25%)
Outpatient Exclusion (30%)
20% Co-payment (25%)
VND 50,000,000 Inpatient Benefit Deductible (20%)

Other Plan
Beneficiary information (for PA only)
Relationship to Insured Person
PAYMENT OPTION	Annual Semi-Annual (surcharge is applied)	Annual Semi-Annual (surcharge is applied)	Annual Semi-Annual (surcharge is applied)	Annual Semi-Annual (surcharge is applied)
PREFERRED COVERAGE EFFECTIVE DATE (DD/MM/YY):

C-QUESTIONNAIRES

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.

	Insured Person 1	Insured Person 2	Insured Person 3	Insured Person 4
1. - Are you currently covered by a medical policy? (If YES, please provide a copy of the policy and benefit schedule)
- Have you had any medical insurance application or policy declined, rated, restricted, or cancelled, at any time in the past? If YES, please explain:	Yes No	Yes No	Yes No	Yes No
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.	Yes No	Yes No	Yes No	Yes No
2.2 Heart or circulatory conditions? Ex: high/low blood pressure, angina/chest pains, heart attacks or heart failure, coronary arteries, ischemia, deep vein thrombosis, varicose vein, etc.	Yes No	Yes No	Yes No	Yes No
2.3 Tumors, growths or cancer? Ex: polyps, benign growths or cysts, lymphomas, any cancers or pre-cancerous conditions, etc.	Yes No	Yes No	Yes No	Yes No
2.4 Brain or nervous system conditions? Ex: stroke/transient ischemic attack (TIA), syncope, seizure or epilepsy, migraines, multiple sclerosis, meningitis, neuritis, etc.	Yes No	Yes No	Yes No	Yes No
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.	Yes No	Yes No	Yes No	Yes No
2.6. Eyes, ears, nose or throat? Ex: glaucoma, cataracts, retinal detachment, hearing difficulties/loss, tonsillitis, sinusitis, etc.	Yes No	Yes No	Yes No	Yes No
2.7. Breathing or respiratory conditions? Ex: asthma, chronic obstructive pulmonary disease (COPD), emphysema, shortness of breath, tuberculosis (TB), all kind of respiratory allergies, Coronavirus infection (including Covid-19), etc.	Yes No	Yes No	Yes No	Yes No
2.8. Urinary, kidney, ureter, bladder, urethral or prostate conditions or STI?	Yes No	Yes No	Yes No	Yes No
2.9. Stomach, liver, gall-bladder, pancreas, or digestive system conditions?	Yes No	Yes No	Yes No	Yes

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Please leave your information in the form, we will contact you within 24 hours