CUSTOMER INFORMATION
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?
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)?
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
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
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
PREFERRED COVERAGE EFFECTIVE DATE (DD/MM/YY):
C-QUESTIONNAIRES
We 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. We 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. We further understand that the premium is based on the Insured Person(s) residency in Vietnam. We 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 our health, to give to Pacific Cross Vietnam any such information. A photographic copy of this authorization shall be valid as the original.
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:
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 vein 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 test or investigations, for any of the following conditions?
3.1 Eyes, ears, nose or throat?Ex: glaucoma, cataracts, retinal detachment, macular degeneration, hearing diddiculties/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. (if the space provided is insufficient, please use a separate sheet for each Insured Person.)
Insured Person 1
Insured Person 2
Insured Person 3
Insured Person 4
E-DECLARATION
We 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. We 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. We further understand that the premium is based on the Insured Person(s) residency in Vietnam. We 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 our health, to give to Pacific Cross Vietnam any such information. A photographic copy of this authorization shall be valid as the original.
SIGNATURE AND NAME
Please note
(i) We will not be able to process your application if any sections are left incomplete or any necessary questions left unanswered. (ii) lease submit the completed Healthcare insurance application form with your original signature to Pacific Cross Vietnam in order to receive your official policy package. If the Healthcare insurance application form is not bound at the spine, please sign in each page.