Application Form

AXA INSURANCE SINGAPORE PTE LTD
8 Shenton Way, #27-01 AXA Tower,
Singapore 068811
Customer Care Department #B1-01
 1800 880 4888(Within Singapore)
(65) 6880 4888(International)  (65) 6338 2522
www.axa.com.sg
Co. Reg No. 196900406D
GST Reg No. M2-0009922-2
Application Form
Group Leaver
A. Know Your Client
Confidential Fact Find for
By your Insurance Advisor
(Client’s Name)
(Name of Advisor)
(Account Code)
Important Notice to Clients
For General Agents/Banks
Your insurance adviser is a representative with AXA Insurance and can advise you on the products of:
1) AXA Insurance Singapore Pte Ltd 2)
3)
For Insurance Brokers/Financial Advisers/Banks
Your insurance advisory is a broker with
.
As an insurance broker, your advisor is able to source for and objectively recommend the products of various insurance companies to best meet your
insurance needs. Your advisor is required to disclose to you the insurance companies from which he/she sources the products.
Standard Statement Applicable to All Advisors:
Your advisor must have sufficient information before making a suitable recommendation. The information that you provide on your financial situation
and your particular needs will be the basis on which advice will be given.
A policy purchased without the proper completion of a “Know Your Client” form may not be appropriate to your needs.
Application Type
Client’s Choice
1. ❏ I/We wish to disclose all information requested for in this Form. (Please complete and sign “Know Your Client” and all sections of “Our Advice
and Reason Why”)
2. ❏ I/We wish to receive product advice only. (Please complete and sign “Know Your Client” and sections 2 & 3 of “Our Advice and Reasons Why”)
3. ❏ I/We do not wish to receive any advice from my/our advisor. (Please complete and sign “Know Your Client”)
I/We acknowledge that the insurance advisor has provided me/us with a copy of the completed “Know Your Client” Form.
Advisor’s Declaration:
I declare that the information provided to me is strictly confidential and is only to be used for the purpose of fact-finding in the process of
recommending suitable insurance products, and shall not be used for any other purposes.
Signature of Client (on behalf of all applicants)
Signature of Advisor
Date:Date:
B. Our Advice and Reasons Why
Section 1 – Analysis and Calculation Worksheet
(a) Personal Priorities (Please tick)
Your Health Insurance Concerns
Level of Concerns
Low
Medium
High
Cover for hospitalisation expenses
o
o
o
Cover for outpatient medical expenses
o
o
o
Cover for major illnesses (e.g. cancer, kidney dialysis)
o
o
o
Cover for loss of income due to illness or sickness
o
o
o
1
(b) Medical Expenses (also known as Hospital / Surgical Expenses)
(i)
Which type of hospital do you or your family members prefer in the event of hospitalisation?
Private / Public*
(ii) What type of hospital ward do you or your family members prefer in the event hospitalisation?
1 / 2 / 4 / 6 bedded*
(iii) Do you have an existing hospitalisation insurance plan?
Yes / No*
(iv) Is your existing policy an individual policy or Group Employee Benefits policy?
Individual / Group*
Section 2 – Advisor Analysis and Recommendations
Total Health Insurance Budget :
per year.
Advisor’s recommendations
Reasons for recommendations
Hospital/Surgical
Expense Protection
à InternationalExclusive
à SmartCare OptimumEnhanced
à SmartCare Executive
Remarks
Replacement Y/N*
Note: If this product is intended to replace any existing health insurance policy, advisor should state the reasons for recommending a replacement
Section 3 – Acknowledgement
Client’s Declaration:
I/We understand that the above recommendation(s) is/are based on the facts furnished in the “Know Your Client” Form; and I/We agree / do not
agree* with the proposed recommendation(s).
If I/we should decide to switch from one health insurance product to another health insurance product, I/we understand that:
(a) I/We may not be insurable at standard terms
(b) I/We may have to pay a different premium
(c) Terms and conditions may defer
Statement by Advisor:
The recommendations in this document are based on your personal information collected in the “Know Your Client” Form, the prevailing healthcare
financing system and information on healthcare costs obtained from sources believed to be reliable and accurate to the best of my knowledge. If
there has been any change in your circumstances since completing that form, please notify your advisor as it may affect the needs analysis process.
The recommendations may not be appropriate in the event of a partial or inaccurate completion of the “Know Your Client” Form.
Signature of Client (on behalf of all applicants)
Signature of Advisor
Date:Date:
C. Declaration For Products Summary
I hereby confirm that the following documents were given and the contents have been explained to me satisfactorily:
(a) Your Guide to Health Insurance and;
(b) Product Summary
Signature of Client (on behalf of all applicants)
Signature of Advisor
Date:Date:
For Office Use Only – INTERNAL
I understand that the recommendation(s) is/are based on the facts furnished in the “Know Your Client” Form; and I agree / do not agree* with the
proposed recommendation(s).
Comments (necessary if in disagreement with recommendation) :
Remedial Action:
Signature:
*Circle as appropriate.
2
Name:
Position:
Date:
D. Application Details
Important Notes
1. Under Section 25(5) of the Insurance Act Cap 142 or any subsequent amendment thereof, you are to disclose in this Application form, fully and
faithfully, all the facts which you know or ought to know, otherwise the policy issued may be void.
2. Please complete this form by answering carefully all questions. It is important that a complete answer be given to every question including dates
where applicable in order to avoid unnecessary delay in the processing of this application. Any question not answered on this form will be taken as
an answer in the negative. Please complete in BLOCK LETTERS and tick the appropriate boxes.
3. This policy is protected under the Policy Owners’ Protection Scheme which is administered by the Singapore Deposit Insurance Corporation (SDIC).
Coverage for your policy is automatic and no further action is required from you. For more information on the types of benefits that are covered
under the scheme as well as the limits of coverage, where applicable, please contact your insurer or visit the GIA or SDIC websites (www.gia.org.sg
or www.sdic.org.sg).
1. Personal details of the applicant (please keep us informed of any change of your address)
Name of applicant – surname:
Given name:
Gender:
NRIC No. / FIN / Passport no.:
Date of birth:
*
Marital status: dd / mm / yyyy
Nationality:
*
Single
Married
Principal country of residence1 and address:
Correspondence address if different from principal country of residence:
Have you been in Singapore for more than 182 days at the time of application?
Telephone no.: country code
1
area code
phone no.
Yes
Fax no.:
No
Mobile no.:
Email:
Occupation/job nature:
Existing AXA Group Policy no.:
Date of leaving the group scheme:
The country where you live or intend to live for most of the year being 185 days or more and which will be shown as your address and place of residence in our records.
2. Your Choice of plan
Option 1: InternationalExclusive
Plan:
❏ Plan A
❏ Plan B
❏ Plan C
*Zone:
❏ 1 ❏ 2 ❏ 3 ❏ 4 ❏ 5 ❏ 6
^Annual Deductible
and Co-insurance:
❏ Option 1
❏ Option 2
❏ Option 3
Area of cover:
❏ Worldwide
❏ Worldwide excluding USA
❏ Asia
Plan to commence on
(dd/mm/yyyy) for one year. No liability will be accepted until this application has been accepted by
AXA and the premium is received. This cover will be subjected to no change in information as declared by you in this application form and at the time
of commencement of the plan. Please declare to us any change in information as soon as it is known to you. Failure to do so may result in claims or
benefits being refused or cover withdrawn.
* Please refer to the InternationalExclusive Product Summary – Premium Table for your applicable zone.
^ Please refer to page 20 for the Annual Deductible and Co-insurance options.
Option 2: SmartCare OptimumEnhanced
Basic Cover
Hospitalization Benefits
Platinum Plan
Gold Plan
(Refer each plan detail in Group Leaver – SmartCare Optimum
Silver Plan
Enhanced
product summary)
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Option 3: SmartCare Executive
CHOICE OF PLAN & OPTIONAL DEDUCTIBLE &/OR CO-PAYMENT
Private Hospital Plan
Public Hospital Plan
❏ Plan A
❏ Plan B
❏ Plan C
❏ Plan D
❏ Plan E
❏ Plan F
Premium Discount
Deductible
Co-payment
Premium Discount
Deductible
Co-payment
o 10%
o 30%
o 45%
S$0
10%
S$0
10%
S$2,000
0%
S$1,000
0%
S$2,000
10%
o 10%
o 30%
o 40%
S$1,000
10%
Note: The deductible & co-payment apply to Hospital & Surgical Benefits except Emergency Outpatient Treatment (due to accident only) and Major Organ Transplant.
(Refer each plan detail in Group Leaver – SmartCare Executive product summary)
3. Bank account details
(for claim payment purposes only)
Account holder name:
Bank name:
Account no.:
4. Family member(s) to be covered
Is the applicant one of the persons to be covered? o Yes o No
1st Family member
Details
2nd Family member
3rd Family member
Surname
Given Name:
Relationship to Applicant:
o Spouse
o Child
o Spouse
o Child
o Spouse
o Child
o M
o F
o M
o F
o M
o F
o Plan A
o Plan B
o Plan C
Nationality:
Principle Country of Residence*:
NRIC No. / FIN / Passport no.:
Date of Birth (dd/mm/yy):
Gender:
Occupation (Specify nature
of duties):
Height:
Weight:
Please indicate your choice of cover if you have selected Option 1 – InternationalExclusive Plan.
Plan Option:
Zone#
Area of Cover
^Annual Deductible and
Co-insurance:
o Plan A
o Plan B
o Plan C
o Zone 1
o Zone 2
o Zone 3
o Zone 4
o Zone 5
o Zone 6
o Worldwide
o Worldwide excluding USA
o Asia
o Option 1
o Option 2
o Option 3
o Plan A
o Plan B
o Plan C
o Zone 1
o Zone 2
o Zone 3
o Zone 4
o Zone 5
o Zone 6
o Worldwide
o Worldwide excluding USA
o Asia
o Option 1
o Option 2
o Option 3
o Zone 1
o Zone 2
o Zone 3
o Zone 4
o Zone 5
o Zone 6
o Worldwide
o Worldwide excluding USA
o Asia
o Option 1
o Option 2
o Option 3
*The country where you live or intend to live for most of the year being 185 days or more and which will be shown as your address and place of
residence in our records.
Additional family members to be covered under the same application must be living with you. If you want to cover family members not living with you,
please use a separate application form.
#Please refer to the InternationalExclusive Product Summary – Premium Table for your applicable zone.
^Please refer to page 20 for the Annual Deductible and Co-insurance options.
4
5. Confidential medical history (Declarations must be made in writing on this application. Verbal declarations WILL NOT be accepted)
Please consider the following two questions as they
apply to each of the people named. Answer each
question by clearly ticking one of the corresponding
Yes/No boxes.
1. Have you, or anyone else to be insured under this
policy, had treatment in hospital or consulted a
specialist in the last 12 months?
Applicant
1st Family member
2nd Family member
3rd Family member
Name
Name
Name
Name
Yes
No
Yes
No
Yes
No
Yes
No
2.Do you, or anyone else to be insured under
this policy, have any consultation, treatment,
investigation or test planned or pending (this
applies whether it is to be provided by a Specialist
or GP)?
If the answer is yes, please provide details below.
Name
Nature of illness /
Disability
Detail of treatment /
investigation / tests
Date of treatment /
investigation / tests
Need for any further
treatment
or consultation
Present state of
health in this respect
6. Personal Data
I confirm that the information I have provided is my personal data and, where it is not my personal data, that I have the consent of the owner of such
personal data to provide such information.
By providing this information, I understand and give my consent for AXA Insurance Singapore and AXA Life Insurance Singapore (collectively “AXA”) and
their respective representatives or agents to:
(a) Collect, use, store, transfer and/ or disclose the information, to or with all such persons (including any member of the AXA Group or any third
party service provider, and whether within or outside of Singapore) for the purpose of enabling AXA to provide me with services required of an
insurance provider, including the evaluating, processing, administering and/ or managing of my relationship and policy(ies) with AXA, and for the
purposes set out in AXA’s Data Use Statement which can be found at http://www.axa.com.sg (“Purposes”).
(b) Collect, use, store, transfer and/ or disclose personal data about me and those whose personal data I have provided from sources other than
myself for the Purposes.
(c) Contact me to share with me information about products and services from AXA that may be of interest to me by post and e-mail and
❏ By telephone ❏ By fax ❏ By text message
7. Your signature and declaration
1. I/We declare that the above answers are full, complete and true and agree that they shall form part of my/our application which shall be the
basis of the contract of insurance.
2. I/We understand that this Policy shall only be effective following full annual premium payment and subject to the acceptance and approval of this
application by AXA Insurance Singapore.
3. I/We declare that I/we do not have any insurance that was terminated in the last 12 months due to breach of any premium payment condition.
4. I/We also agree that in case of any claims, I/we authorise any hospital, physician or other person who has attended to us, or examined us or is
authorised to maintain medical records to disclose when requested to do so by AXA Insurance Singapore, any and all information with respect to
any illness or injury, medical history or treatment. A photocopy of this authorisation shall be considered as effective and valid as the original.
5. I/We also understand that membership cards issued for the policy are to be used only for admissions to hospitals for treatments falling under
the scope of the policy and in the event the charges incurred are not claimable from the policy for any reason, I/we shall undertake to pay AXA
Insurance Singapore within 30 days from the receipt of all expenses that are not claimable under the policy including the interest, if any levied
by the hospital. I/We further agree to sign the MediSave Authorisation form if required at the hospital notwithstanding the production of the
membership card. I/ We also agree to return the membership card upon request from AXA Insurance Singapore or on termination of the policy.
6. I/We understand that AXA Insurance Singapore reserves the right to request for a copy of the latest medical report from me/us at my/our own
expense should further medical information be required.
Signature of client (for and on behalf of
all persons to be insured)
Name of client
Date
5
Payment Method
CHEQUE – Crossed and made payable to AXA Insurance Singapore Pte Ltd.
o
Bank:
Cheque Number:
Choose only ONE payment mode
0% Interest Free Installment Plan1 (Applicable for Visa and MasterCard Only)
Single Deduction
o AMEX
o MASTERCARD
o OCBC
o DINERS
o VISA
o DBS
o POSB
o UOB
Installment Period
Issuing Bank:
o 6 Months
o 12 Months
Cardholder’s name:
State Relationship2 (where cardholder is not the insured):
Card No.:
Expiry date: M M
Y Y Y Y
Card Verification Value (CVV)3:
Contact No:
Cardholder’s Signature:
Date:
Only for participating Banks and subject to their Card Agreement Terms & Conditions. Minimum premium of S$200 is required for OCBC and S$500 for DBS/POSB/UOB.
Your security is our concern. If cardholder is not the Insured nor the insured’s spouse, parent, parent-in-law, child or sibling, AXA Insurance reserves the right to reject payment via credit card.
3
CVV – For Visa & MasterCard, CVV is the last 3-digit no. printed just above the signature panel in reverse italics on the back of your card. For Amex, it is the 4-digit no. printed on the front of the card above
the card number.
1
2
Additional information
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For AXA use only
Underwriting terms accepted by applicant
*
Yes
*
Underwriter’s stamp
6
Date
Print name
No
Authorized signature
Membership number
Effective date
NPE/GrpLeaver/Appform/Aug 2015
Underwriting terms pertaining to this application