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Buyer
APPLICANT'S DETAILS
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No. ID {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }
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Mobile Phone {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }
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Email {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }
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Full Address {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }
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Premium Payment {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }
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Bank Account
Bank
Branch
Account No.
Account Name
Bank Account {binding ItemNumber}
Bank {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }
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Branch {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }
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Account No. {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }
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Account Name {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }
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Insured
Insured # {binding ItemNumber}
Relationship {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }
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Full Name {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }
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Birthdate {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }
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Gender {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }
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Smoker {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }
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No. ID {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }
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Occupation {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }
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Body Height {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }
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Body Weight {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }
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Bingung dalam membuat kustomisasi jaminannya? Baca panduannya disini.
GLOBALIS
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Area of Cover {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }
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High Cost Provider Access {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }
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Annual Deductible {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }
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Hospital Room Type {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }
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Outpatient Annual Limit {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }
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Outpatient Direct Billing Services {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }
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Outpatient Co-Insurance {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }
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Premium Frequency {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }
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Benefit Details {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }
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Insurance
YOUR INSURANCE DETAILS
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If ‘Yes’, please provide the reason for rejection/cancellation {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }
If ‘Yes’, please provide the terms or conditions applied {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }
Medical
MEDICAL DECLARATION
Failure to fully declare medical conditions or symptoms may invalidate the policy without refund of paid premium and we may seek the return of any benefits already paid to you. Please tick if your answer is "Yes".
DATA PROTECTION NOTICE
We take the protection of your personal data seriously. We describe below how we collect, use and protect it.
We will need to collect, use, process, and/or disclose your personal data or personal information about you to process, administer, and/or manage your relationship, account and Policy with us. Such personal data includes (i) information set out in this form and any other personal information provided by you or possessed by us; and (ii) your claims.
Such personal data will be collected, used, processed, and/or disclosed by us for the purposes of:
- considering whether to provide you with the insurance for which you applied;
- processing your application for underwriting and insurance;
- administering and/or managing your relationship, account and/or policy with us;
- processing and/or dealing with any claims, including the settlement of claims and any necessary investigations relating to the claims, under your Policy;
- carrying out due diligence or other screening activities (including background checks) in accordance with legal or regulatory obligations or risk management procedures that are required by law or that have been put in place by us;
- carrying out your instructions or responding to any enquiries by you;
- dealing in any matters related to the products and services to which you are entitled under this Policy and for which you are applying or have applied - including the mailing of correspondence, statements, invoices, reports or notices to you, which could involve disclosure of personal data;
- investigating fraud, misconduct, any unlawful action or omission, whether relating to your application, your claims or any other matter related to your policy, and whether or not there is any suspicion of the aforementioned;
- complying with applicable law in administering and managing your relationship with us; and/or
- sending you marketing, advertising, promotional information about our products and services that we may be selling or marketing (unless you have specifically opted out or have written to us to stop sending you such information), through such modes of communication as: post/mail, telephone calls, text messages (SMS or WhatsApp), emails, and facsimiles.
(collectively the “Purposes”).
We may collect personal data from sources other than yourself, personal data about you, for one or more of the above Purposes, and thereafter using, processing, and/or disclosing such personal data for one or more of the above Purposes.
Your personal data may be disclosed by us to the participating Insurers, Claim Administrators, Assistance Companies, third-party service providers or vendors, and to our professional advisors, wherever they are sited, for one or more of the above Purposes, as such parties, if engaged by us, would be processing your personal data for us for one or more of the above Purposes.
We may share, if necessary, your medical information with your any doctor, clinic or hospital to ensure appropriate care is provided to you and to ensure any claims from you can be properly assessed for benefits. We may also share your information with your Intermediary, if you have requested and authorized us to do so.
If you have declared any personal data relating to other individuals, you agree to inform the individual(s) about the content of our Data Privacy Policy and obtain their prior consent to act on their behalf to allow for the collection, use, disclosure, and transfer of their personal data in accordance with our Data Privacy Policy.
You have the right to request a copy of any information we hold on you, and to seek correction of any incorrect information held. Where possible, we will correct the information held in our files or on our systems as quickly as possible from such a request being made.
For full details about our Data Privacy Policy, please visit: www.safemeridian.com
By signing this form, you confirm you have read, understood, agreed to the above provisions, and consented to SAFE MERIDIAN:
- collecting, using, processing and/or disclosing your personal data for one or more of the Purposes as described above;
- collecting personal data about you from sources other than yourself and using, processing and/or disclosing the same, for one or more of the Purposes as described above; and
- disclosing and/or transferring your personal data to the participating Insurers, Claim Administrators, Assistance Companies, third-party service providers or vendors, and to our professional advisors, wherever they are sited, for one or more of the Purposes as described above.
DECLARATION & AUTHORIZATION
Please read the following declarations carefully and only sign if you understand and accept them.
- I understand that I am applying for a SAFE MERIDIAN policy, underwritten by GREAT EASTERN, on behalf of all the person(s) named in this application, and that this application is subject to SAFE MERIDIAN’s written acceptance.
- I acknowledge that I have received, read and understood the brochure and policy wording which explains the terms and conditions, Table of Benefits, definitions and exclusions of the policy. I understand that this Application Form, Policy Wording, Insurance Certificate, and the Member Handbook are contractual documents of the Individual policy for which I am applying, and the terms stipulated will be binding upon me and the person(s) named in this application. I accept that cover shall be provided in accordance with these documents.
- I declare that I have the authority to act on behalf of the person(s) named in this application and have obtained their authorization to release the sensitive personal information provided herein, and that all information supplied herein is true and complete, including answers that are not in my own handwriting.
- I understand that if the information provided in this application is false, incomplete or misleading, or if a submitted claim is false, fraudulent or intentionally exaggerated or incomplete, it may result in the claims being rejected or not fully paid, I may become responsible for any costs which were incurred in respect of the said claims, and that the Insurer may terminate this policy without refund of the premiums already paid.
- For the purpose of this application, I hereby consent and authorize any doctor who has ever treated or advised any of the person(s) named in this application, to provide SAFE MERIDIAN with any and all information it may require in connection with the underwriting of the application and/or in respect of any claims or use of direct billing services under this policy. I understand that should further medical information be required in connection with the underwriting of this application and/or in respect of any claims under this policy for the person(s) named in this application, SAFE MERIDIAN reserves the right to request a copy of the latest medical reports from me at my own expense.
- I understand that, as the legal policyholder of this policy, all correspondence, including claims correspondence for any person(s) named in this application will be sent to me. I understand that if any person covered by the policy and aged 18 or over wants that to change, they must take out a policy in their own right.
- I agree that in the event SAFE MERIDIAN incurs any costs not eligible for benefits under the policy from medical treatment received within the Direct Billing Provider Network by any of the person(s) named in this application, I will be liable to repay the amounts in full to SAFE MERIDIAN within 60 days of being notified. I understand and confirm that should I not repay SAFE MERIDIAN these costs by the deadline provided, my policy may be suspended until such amount has been repaid in full and/or SAFE MERIDIAN may offset the amounts from future eligible claims submitted. I accept that regardless of these being implemented, I shall remain legally liable to repay SAFE MERIDIAN until the debt is repaid in full.
- I recognize that should SAFE MERIDIAN receive late claims from me or from a Direct Billing Provider for any person(s) named in this application for treatments obtained in a period which has been determined to be a “no claims period”, any discount on usual premiums payable that may have been granted as a result will be cancelled and I will be liable to pay the full premium otherwise due for the renewal in question. I accept that my policy may be suspended until such outstanding amount is paid.
- If I have indicated that I wish to pay by credit card, I authorize SAFE MERIDIAN to charge the premiums invoiced on or before their due dates to my card, and the premiums for all subsequent renewals of the policy, until such time as I provide written notice that I wish to terminate my policy or change my method of payment. I accept that any such notice from me will apply only to premiums not already charged to my card.
- I understand that should I fail to pay premiums in full due by their due dates for any reason, my policy shall lapse and SAFE MERIDIAN, its participating Insurers, Claim Administrators and Assistance Companies will not be liable for and will not pay any claims or provide any service.
- I understand that if I am able to claim any cost incurred to my employer or to another insurer or government program, the GLOBALIS policy will only be liable to pay eligible costs not covered by those entities.
- I undertake to inform SAFE MERIDIAN immediately in writing of any changes in the facts declared in this application, such as a change in the state of health of any person(s) named in it, that occurs before the start date of the policy.
- I understand that this application form is valid for two (2) months from the date of completion and signing.
- I understand that upon receipt of my insurance documents, if I feel that the policy does not meet my needs, I may cancel the policy from inception and receive a full refund of the premium I have paid, provided I notify SAFE MERIDIAN within 14 days of joining and provided no claims has been submitted and no direct billing services have been obtained.
- I understand that my policy will be automatically cancelled for any person(s) named in this application that becomes a resident of a country that is not covered by this policy (e.g. USA).
- I acknowledge that it is my responsibility to check whether any person(s) named in this application is/are subject to any local compulsory health insurance requirements and to ensure that my chosen healthcare cover is legally appropriate in my country of residence. I acknowledge that neither SAFE MERIDIAN nor GREAT EASTERN may be held liable for any regulatory, tax or other issue affecting me as the buyer within my own country of residence.
- I agree to the above declarations and authorizations required to process this application and understand that any cover will be provided in accordance with the terms and conditions of the GLOBALIS policy upon acceptance.
- I hereby authorize SAFE MERIDIAN to share the personal data of myself and of each Dependant named in this Application, including medical history and details of claims lodged, to my intermediary and the company he/she works for, as named below. This authorization will remain in place until I provide a written request to SAFE MERIDIAN to revoke it.
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Pemohon
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Please choose "SEND REQUEST" below, and your application will be processed immediately.