2015 Application Form Please send completed application forms to: Vhi International Sales Team, Vhi Healthcare, IDA Business Park, Purcellsinch, Dublin Road, Kilkenny. Policyholder Details Title: First Name: Surname: Date of birth: / / Gender: Male Female Occupation: Nationality: Home Address: Mailing address abroad: Telephone/home: Telephone/abroad: Email: Please note that by providing your email address, you understand that you will receive your policy and renewal documentation electronically. If you wish to receive by post, tick here. Is the policyholder to be insured on Vhi International? Yes No Are you/your dependants currently insured with Vhi Healthcare? Yes No If you/your dependants are insured with another private health insurer, please state the name: Please state your membership number: IntlApp2 Travel Details Only Corporate Members need complete this section Your Details 1. Reason for travelling: Company name & address: Vhi Membership number: 2. Name of country (and nearest city/town) where you will be based: Is your company funding your Vhi International premium? Contact phone number: Yes Email address: If no fixed location, please tick: 3. Expected length of time abroad: / 4. Date of departure: No Partially New Vhi customers / We will contact you as necessary about the products you currently hold with us. We would like your permission to contact you about other Vhi products or services. Please indicate your preferences below. We will activate your policy from a date as close to your date of departure as possible. If you have already moved abroad we will set up your policy from a current date. Do phone me about other Vhi products or services Cover Details (tick relevant boxes) Area required: Area 1 – Europe Area 3 – Worldwide (all countries) Level of cover required: Level 1 Level 2 Optional Add-ons: Dental Insurance €215 per person Additional persons to be insured*: Full Name Date of birth Relationship Nationality Student** (please tick) SEPA Direct Debit Mandate Creditor name: Vhi Healthcare Creditor address: Vhi House, Lr. Abbey Street, Dublin 1 Creditor identifier: IE46SDD300001 Don’t send me post about other Vhi products or services By signing this mandate, you authorise: (a) Vhi Healthcare to send instructions to your bank/building society to debit your account; Your current communication preferences held for sending you information about other Vhi products or services will continue to apply. If you wish to change these preferences, please contact us at 1890 44 44 44 or online at Vhi.ie/contact/.” (b) Your bank/building society to debit your account in accordance with the instructions from Vhi Healthcare. As part of your rights, you are entitled to a refund from your bank under the terms and conditions of your agreement with your bank. A refund must be claimed within 8 weeks starting from the date on which your account was debited. Data Protection Unique Mandate Reference (UMR): (to be completed by Vhi Healthcare) Type of payment: Recurring ü The information which you provide to the Vhi Group (“Vhi”) in this form will be used within the Vhi group of companies and by the insurer and their representatives for processing your application and claims, customer services and for the administration of any healthcare related products and services of which you and any other person on your policy avail. Data may also be used for statistical analyses and the detection and prevention of fraud. We may share your data with trusted third parties who process data on our behalf, inside and outside of the European Economic Area. We may also share your data with other insurers to verify your cover, and with state bodies as required by law. Travel Insurance benefits €60 per person (Included on Level 1 as standard, without charge) Yearly Do phone me about other Vhi products or services Existing customers Area 2 – Worldwide (excl.USA & Caribbean) Payment Option: Monthly By including your details in this form, you explicitly consent to Vhi processing your details for these purposes. You also confirm that you have explained to each person who is included on your policy why we may ask for this information and what we will use it for, and that each person has agreed to this. Customer Details (Please complete all required fields marked below*) *Name: *Address: *IBAN: You have the right, subject to certain exemptions, to access any personal data that we hold about you (for which we may charge you a small fee) and to have inaccuracies corrected. If you wish to avail of these rights, please write to the Data Protection Officer, Vhi House, 20 Lower Abbey Street, Dublin 1. *BIC: Vhi’s Data Protection Statement contains a further detailed breakdown of the personal data we collect in relation to our customers and how we use that personal data. The Data Protection Statement can be found at Vhi.ie or should you wish to contact us on 1890 44 44 44, you can request a hard copy. X For office use only *Signature(s): X Your rights regarding this mandate are explained in a statement that you can obtain from your bank. S.P.I.N. * Where dependants require different cover to the policyholder, please supply details in a covering letter. **Where this box is ticked, evidence of full-time student status must accompany this form i.e. letter from university. Membership number: Application date: Please send to: Vhi Healthcare, IDA Business Park, Purcellsinch, Dublin Road, Kilkenny. Completed by: For information purposes only: Vhi Healthcare will notify you at least 7 days in advance of the first direct debit on your account and any time the amount to be debited changes.
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