• SUBSCRIBER
  • PREMIUM/ TERM
  • PERSONS TO BE INSURED
  • HEALTH QUESTIONNAIRE
  • SIGNATURE AND RECEPTION OF THE QUOTE

ASUBSCRIBER

As a subscriber to the Plan, you are the legal representative to Golden Care, on behalf of all persons who will be insured under this application form.
A subscriber may choose not to be insured themselves, if the cover is required for their dependent(s) only.

Address of correspondence is the same as registered address

BPREMIUM/ TERM

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

CPERSONS TO BE INSURED

You will be able to add a member of your family or a person outside your family and select their area of cover. After reading the following specifications for this section, please provide information on:
Area of coverage:
  • Area 1: Worldwide limited to 30 days per year in the United States and Canada
  • Area 2: Worldwide
Children to be insured:
  • If your child is between 21 and 24 years old and a full-time student, he/she benefits up to 20 year-old premium rate. A proof of education status may be required in the event of a claim.
  • A child aged up to 20 years old applying alone will be charged the 21 to 24 year-old rate. If several children apply together, the oldest will be charged the adult rate.

Policyholder: Do you wish to be insured?

If yes, select your area of coverage

Your premium:

Do you wish to insure another person?


DHEALTH QUESTIONNAIRE

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



ESIGNATURE AND SUBMISSION OF THE QUOTE

ESTABLISHMENT OF THE BENEFICIAL OWNER’S IDENTITY

Within the framework of the Swiss FINMA’s Anti-Money Laundering Act, we have to recognise the beneficial owner
We would be grateful if you could upload your identity document.



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

Statement: I hereby apply to be enrolled in the Golden Care Plan together with the persons on the present form. I declare in the name of these persons :
  • I understand the above answers are confidential and shall be used for the underwriting procedure of my application by Golden Care Services ;
  • The above questions are accurately represented and are, to the best of my knowledge and belief, full, complete and true, and that I do not have any knowledge of any circumstance that would affect the result of the evaluation by Golden Care Services related to my application for insurance;
  • I understand any false or inaccurate declaration shall be considered retroactively as a waiver of benefits and shall lead to the immediate cancellation of the Plan;
  • I am aware the Plan shall be effective at the date mentioned on each Insured’s certificate of insurance, and that the present form together with my/our medical declaration, certificate of insurance and general conditions of the Plan n°GCCHEVERI008EN,, Underwritten by Global Health and Accident Insurance Limited which is regulated by Guernsey Financial Services Commission (licence number : 2291879). The general conditions form the basis of the contract between the insurer and the insured person(s);
  • I am aware Golden Care Services may require medical reports or a medical examination at my expense before assessment of my application;
  • I authorise Golden Care Services to obtain from doctors, insurers and other service providers, and to pass on to the same, information, including personal data, necessary for the evaluation of the insurance risk and for the management of the contract thereof;
  • I understand that refusal to submit medical information by any Insured or physician, clinic, hospital, or institution shall be considered a waiver of benefits by such Insured and the insurer shall have no further obligations towards such persons ;
  • I have read and fully understood the summary of the principal exclusions, and specifically those related to pre-existing conditions ;
  • I understand that I must notify Golden Care Services of any change in health or of any change to the information provided which takes place between the time this form is completed and the time coverage becomes effective, and that failure to do so may result in the rejection of a claim or my insurance coverage being void.

Signature of the subscriber in the name of all the persons to be insured:

Clear