• PERSON TO BE INSURED
  • PREMIUM/ TERM
  • HEALTH QUESTIONNARY
  • SIGNATURE

APERSON TO BE INSURED

BPREMIUM/ TERM

(At earliest at noon, the day following the receipt of your application)

CHEALTH QUESTIONNARY

If you answer «yes» to any of the following questions, StudyProtect Services requires that you mention the specifications asked forin the fields provided. This information is compulsory for the assessment of your application.

Do you have any general treating doctor?*
1. Have you consulted a doctor in the last 3 years for any reason other than a check-up?*
2. Have you ever been hospitalized in internal medicine?*
3. Have you ever stayed in a detoxification, cessation or treatment facility?*
4. Have you ever had any abnormalities in your biological tests?*
5. Have you ever consulted a doctor for a mental illness or psychological disorder?*
6. Are you currently under medical treatment for a mental illness or psychological disorder?*
7. Have you ever been diagnosed with a metabolic disorder (diabetes-related disorders, lipids, etc.) or a blood disorder?*
8. Is there a skin condition (eczema, acne, cancer, etc.) or a visual or hearing condition?*
9. Do you have a birth defect/chronic disease/congenital disease or are you suffering from the after-effects of diseases or accidents?*
10. Do you have to undergo an operation or additional examinations in the future?*
11. Are you pregnant?*

ESTABLISHMENT OF THE BENEFICIAL OWNER’S IDENTITY

The undersigned hereby declares (mark with a cross where appropriate) :*

Statement: I hereby apply for the membership of the person to be insured in the StudentCover plan, underwritten by Global Health and Accident Insurance Limited and which is regulated by the Guernsey Financial Services Commission (licence no. 2291879). I declare:

  • Certify that the answers are accurate and, to the best of my knowledge, complete, whole, true and that there are no circumstances which may affect the outcome of the underwriting assessment by StudyProtectServices;
  • To be aware that any false or incomplete statement will be considered retroactively as a waiver of benefits and will result in the immediate cancellation of the contract concerned.
  • Knowing that any reticence or omission to declare a circumstance limiting the validity of the cover gives the insurer the possibility of withdrawing from the contract from the moment he becomes aware of it.
  • To know that the contract will be effective on the date specified on the insurance certificate issued after acceptance of the file and collection of the premium.
  • Know that the insured releases all doctors and paramedical staff who have examined him/her both before and after the claim from professional secrecy.
  • I have read and approved the general terms and conditions of Plan No. GCCHSSST002EN and have passed them on to the insured if I am acting on his/her behalf, and I acknowledge that the benefits are equivalent to the KVG/LAMal but are not identical.

DSIGNATURE

Clear