Application Form

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.