Client Details
A - INSURED PERSON DETAILS
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:
B-PLAN SELECTION
FOUNDATION STANDARD – VND 500,000,000 EXECUTIVE – VND 1,000,000,000 PREMIER – VND 2,000,000,000
In-patient
Out-patient
Additional Benefit
MASTER
Additional Benefit
Discount Options
Beneficiary information: (for Personal Accident Benefit only)
C-QUESTIONNAIRE

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.

1. Are you currently covered by a medical policy
- 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 state the reason:
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.
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.
2.3. Tumors, growths or cancer? Ex: polyps, benign growths or cysts, lymphomas, any cancers or pre-cancerous conditions, etc.
2.4. Brain or nervous system conditions? Ex: stroke/transient ischemic attack (TIA), syncope, seizure or epilepsy, migraines, multiple sclerosis, meningitis, neuritis, etc.
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.
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.
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.
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.
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.
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.
3.6. Auto-immune disorders? Ex: HIV/AIDS, rheumatoid arthritis, systemic lupus erythematosus, scleroderma, etc.
3.7. Skin conditions? Ex: eczema, dermatitis, rashes, psoriasis, acne, moles that itch or bleed, or all kind of skin allergic reactions, etc.
3.8. Gynecological or breast conditions? Ex: irregular periods, fibroids, prolapse, endometriosis, abnormal Pap test, cervix, uterus, ovaries or fallopian tube disorders, etc.
3.9. Any physical defect or congenital condition?
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?
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. I agree to receive any information relating to the policy and insurance benefits from Hung Vuong Insurance Company and its third party administrator - Pacific Cross Vietnam via Email/ SMS/ MMS/ USSD/ Zalo/ Whatsapp/ Viber and other electronic means.