Guidelines on how to complete this Application Form

You must complete the Insurance Membership enrolment Application form in full and tell us all relevant information. Once you have sent us your application, our Medical Underwriting Team will review the details. If you have told us about any medical conditions, we may ask you for more information. We will then assess the information and get back to you with our decision as quickly as possible.
All questions must be answered in full; all signatures and dates must be included where noted; otherwise the application may be returned to you, resulting in a delay in processing and possibly a delay in the effective date of coverage.
Section 7 must be signed by the Principal member. Sections 8 and 10 must be signed by all adult applicants. In line with the European General Data Protection Regulation (GDPR), we will not be able to process your application without these signatures. A parent or guardian should complete these sections for any applicants under the age of 18.

Wherever the following words and phrases appear in this form, they will have the meanings as defined below.

Home country: A country for which you (or your beneficiaries, if applicable) hold a current passport or which is your principal country of residence.

Principal Country of residence: the country in which you and your beneficiaries have as your primary residence and normally live.

BENEFICIARIES TO BE ENROLLED UNDER INSURANCE COVERAGE

Beneficiaries can include your spouse/partner and any children financially dependent on you up to the day before their 18th birthday. We will consider adult beneficiaries for cover up to the day before their 70th birthday. If there is insufficient space for all beneficiaries, please use another Application Form.

First Name

Gender

Principal country of residence

Home Country

PLAN DETAILS

Does the beneficiary drink alchohol?

How many units of alcohol do you drink per week? (1 short = 1 unit, 250ml beer = 1 unit, 1 glass wine = 1 unit)

Has the beneficiary used any form of nicotine in the past year?

If yes, how much per day on average?

Last Name

Date of Birth

Height

Weight

Occupation

Do you want to add another Beneficiary?

Yes

Does the beneficiary wear glasses or contact lenses?

Please state condition

Number of diopters for left eye (this appears on the prescription from the optician)

Number of diopters for right eye (this appears on the prescription from the optician)

First Name

Gender

Principal country of residence

Home Country

PLAN DETAILS

Last Name

Date of Birth

Weight

Height

Occupation

Do you want to add another Beneficiary?

Yes

START DATE OF COVER

Our acceptance of your application for cover is confirmed when we issue your Insurance Membership Certificate and your cover is valid from the start date shown on the certificate.

Please indicate the date you require cover from

PRE-EXISTING MEDICAL CONDITIONS

Pre-existing conditions are medical conditions for which one or more symptoms have appeared at some point during your or your beneficiaries’ lifetime. This applies regardless of whether you or your beneficiaries sought any medical advice or treatment.

We would deem any such condition to be pre-existing if we could reasonably assume you or your beneficiaries have known about it. Your policy will cover pre-existing conditions unless we tell you otherwise in writing.

We will also treat as pre-existing any medical conditions that arise between the date you complete the application form and the later of the following:

The date we issue your Insurance membership Certificate or
The start date of your cover

Pre-existing conditions will be subject to full medical underwriting and if they are not disclosed, they will not be covered. Therefore, it is important that in the periods outlined above, you inform us if there is any change to your and your beneficiaries’ health status or to any material facts (facts likely to influence our assessment and acceptance of this application). In addition, you will need to provide further information, if requested.

HEALTH DECLARATION

Please answer the following questions based on your own and your beneficiaries’ full medical history.

All material facts (facts likely to influence our assessment and acceptance of this application) must be disclosed. If you are in any doubt about whether a fact is material, then you should disclose it to us. Failure to disclose all material facts may invalidate the policy. This health declaration is valid for two months from the date you complete and sign the form.

Have you or any beneficiary been treated, diagnosed, tested, hospitalized, or recommended for treatment for any of the following?

Any heart or circulatory disease or disorder, such as, but not limited to heart attack, coronary artery disease, irregular heartbeat, murmur, chest pain, clots, blood disorder, abnormal blood pressure, high cholesterol, etc.

Any dermatological disease or disorder, such as, but not limited to psoriasis, dermatitis, eczema, allergy, acne, etc.

Any endocrine disease or disorder, such as, but not limited to diabetes, weight problems, gout or thyroid problems or other hormonal imbalances, etc.

Any eye, ear, nose and throat disease or disorder, such as, but not limited to cataract, glaucoma, hearing loss, sinus problems, tonsils, adenoids, etc.

Any gastrointestinal disease or disorder, such as, but not limited to stomach problems, hernia, hemorrhoids, gall stones, colon polyps, Crohn’s disease, colitis, liver problems, etc.

Any muscular or skeletal disease or disorder, such as, but not limited to back, neck or joint pain, arthritis, paralysis, joint replacement, any cartilage and ligament problem, etc.

Any neurological disease or disorder, such as, but not limited to stroke, multiple sclerosis, epilepsy, neurodegenerative disorder, seizures, migraine, Alzheimer’s or other form of dementia, etc.

Any infectious or viral disease or disorder, such as, but not limited to: hepatitis A/B/C, herpes, HIV, malaria, meningitis, blood infection, sexually transmitted disease, etc

Any oncological disease or disorder, such as, but not limited to any cancer, leukemia, lymphoma, tumour, skin lesion, growth, lump, cyst, mole, polyp, naevus, etc.

Any psychiatric or psychological disorder, such as, but not limited to depression, anxiety, chronic fatigue syndrome, eating disorder, alcohol/drug problem, etc.

Any respiratory disease or disorder, such as, but not limited to chronic obstructive pulmonary disorder, asthma, bronchitis, sinusitis, shortness of breath, etc.

Any urological or reproductive organs disease or disorder, such as, but not limited to kidney or urinary tract problem, menstrual impairment, fertility problem, fibroids, endometriosis, testicular or prostate problem, etc.

Any other accident, injury, disease or disorder not already disclosed

Please tell us whether you or your beneficiaries

Please do NOT disclose results of any genetic (DNA or RNA) tests, as these are not required for medical underwriting

Are currently taking any prescribed or over-the-counter drugs, medication, tablets or other treatment.

Are expecting to have a medical review, has been referred for further tests/investigations, or is awaiting results or any treatment due to accident, injury, disease or disorder.

Have undergone any tests or investigations within the last 10 years which resulted in referral for further medical advice or treatment, such as, but not limited to biopsy, colonoscopy, colposcopy, computed tomography (CT), mammogram, magnetic resonance imaging (MRI), Papanicolaou test (PAP), or prostate-specific antigen test (PSA), etc.

Within the past 2 years have you experienced any symptoms or medical complaints such as, but not limited to

Fever and continuous cough (within the last 2 weeks)
Shortness of breath
Severe/ongoing headache
Mole or skin marking that has bled, changed or become painful
Tingling, blurred or double vision
Unexpected weight loss
Bleeding per rectum, change in bowel habit or urine frequency
Loss of sensation, seizures, loss of consciousness
Abnormal bleeding, etc.

Have you been recommended or decided to self-isolate?

DECLARATION

Please read the following declarations carefully

I declare that all information supplied above is true and complete, including those answers that are not in my own handwriting. I also declare that I have not suppressed, misrepresented, or misstated any material I understand that this application will be the basis of the contract between Sinoasia B&R Insurance JSC and myself, and that any false, incorrect or misleading statement or non-disclosure of material medical information may make this insurance null and void.
I undertake to inform Sinoasia B&R Insurance JSC immediately in writing of any changes in my or my beneficiaries’ state of health occurring between completing the Application Form and the start date of the policy.
I agree to waive any rights that I may have to medical secrecy/confidentiality in respect of my medical information in the context of this application for I consent to allow Sinoasia B&R Insurance JSC, and CROSSBORDER HEALTH PARTNERS Ltd, if it considers it appropriate, to check statements concerning my health condition and to check with other healthcare insurers all statements concerning previous or existing contracts I may have applied for.
Subject to legal restrictions, Sinoasia B&R Insurance JSC (or its medical advisers, appointed representatives or third-party experts in case of disputes) may request medical information about Inthese circumstances I authorise all suchpractitioners, physicians, dentists, members of medical professions, and employees of hospitals, health authorities and medical facilities to provide relevant medical information as requested. I also make this statement for my beneficiaries under the age of 18 and for beneficiaries who cannot assess the meaning of this statement.
I confirm that:
I have read and understood the full definitions, benefits, exclusions and conditions of this policy, including the details relating to pre- existing
I have received, read and understood the Insurance Product Information Document and I accept the terms and conditions as summarised there and further explained in my Membership Booklet.
Based on the information provided within these documents and the plan selections that I have made, I believe the product I selected is most suited to my specific insurance needs.
I understand that:
This Application Form is valid for two months from the date of completing and signing
I can withdraw my application in writing by letter, email or fax within 14 days from the date I receive the full terms and conditions of my Provided that I have not submitted a claim, I am then entitled to a full refund of the premium.
I accept that:
It is my responsibility to check the accuracy of the information contained within the Insurance Certificate, once issued. If the content is not in accordance with the Application Form but I enter no protest within 14days following the issue date of the Insurance Certificate, I will be considered to have accepted the offer of cover.
Cover will be subject to the standard terms and conditions that apply at the start or renewal date of the policy and are set out in the Membership
The cover provided by Sinoasia B&R Insurance JSC may not be suitable if my beneficiaries and I are or become resident in countries where local compulsory health insurance restrictions are in place (e.g. UAE).
It is my responsibility to check if I am subject to any local compulsory health insurance requirements in my country of residence and I can confirm that my healthcare cover is legally appropriate or meets my needs as an additional cover.

I have read the declarations above and I accept them.

DATA CONSENT

We need your consent to collect and process your health and other personal data. If you do not give explicit consent, we may not be able to provide you with your policy or process any claims you may be entitled to make. If you agree, we will process your data for the following reasons and activities.

A parent or guardian should complete the consent for any member under the age of 18.

I , and the beneficiaries named below agree with the terms stated in the Data Consent Policy

If I change my mind about my preferences above, including withdrawing my consent to any of these items, I can let my Health Partners know by emailing info@metrohealthhmo.com

METROHEALTH HMO INTERNATIONAL HEALTH PLANS

APPLICANT DETAILS

BENEFICIARIES TO BE ENROLLED UNDER INSURANCE COVERAGE

START DATE OF COVER

PRE-EXISTING MEDICAL CONDITIONS

HEALTH DECLARATION

Please tell us whether you or your beneficiaries

DECLARATION

DATA CONSENT

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