Fillable Printable Insurance Proposal Form - Global Benefits Group

Insurance Proposal Form - Global Benefits Group

26000 Towne Centre Drive

Foothill Ranch, CA 92610 USA

Fax: 949-470-2110

Insurance Proposal Form

Form to be completed by Life Assured - Please print clearly

Section 1.

Applicant Details

1. Title: (Mr/Mrs/Ms/Other) 2. Surname:

3. Forenames:

4. Gender:

5. Date of Birth (mm/dd/yy): 6. Height: 7. Weight:



Male



Female

m / feet lbs / kgs

8. Marital Status:

9. Home Country:



Married



Divorced



Single



Other: ________________

10. Nationality: 11. Country of Residence:

12. Annual Salary: (US$)

13. Occupation: (Please provide full description) 14. Employer's Name and Address

15. Social Security Number (If any):

Country A: ______________________________________ Number: ___________________________________________

Country B: ______________________________________ Number: ___________________________________________

16. Are you entitled to any Social Security or Government plan in the Country of Residence?

(If yes, please provide full details):



YES



17. Are you entitled to any reimbursement from another Insurer?

(If yes, please provide full details):



YES



18. Details of Principal Residence: 19. Anticipated travel patterns for the next 12 months:

Mailing Address: __________________________________

__________________________________

Country: __________________________________

Postal Code: __________________________________

Contact Details:

Home Tel. No.: __________________________________

Mobile Tel No.: __________________________________

Fax No.: __________________________________

Email Address: __________________________________

Destinations: __________________________________

__________________________________

Frequency: __________________________________

__________________________________

Duration: __________________________________

__________________________________

Duties: __________________________________

GBG Ind. App 042408 ?

Page 1

__________________________________

Section 2. Cover Required

Please tick (

✓

) cover required currency of benefits:

US Dollar ($) British Pound (£) Euro (€)

1. LIFE INSURANCE

Sum Assured: _________________

2. LONG TERM DISABILITY

INSURANCE

Benefit (% Salary): ___________ per month with escalation of (Nil or 3%) ___% per annum.

Deferred Period (13 or 26): ________ weeks

3. SHORT TERM DISABILITY

INSURANCE

Benefit (% Salary): ___________ per month with escalation of (Nil or 3%) ___% per annum.

Deferred Period (13 or 26): ________ weeks

Benefit under Short Term Disability are Payable for maximum 5 years.

Cannot be covered in conjunction with Long Term Disability Insurance.

4. ACCIDENTAL DEATH &

DISMEMBERMENT INSURANCE

Sum Assured: _________________

5. WAR & TERRORISM

EXTENSION

An extension for War & Terrorism Coverage (excluding NCB Perils) can be added to the

above benefits, but is subject to Underwriters’ approval and additional premium loading.

6. NCB PERILS EXTENSION

An extension for Nuclear, Chemical and Biological Perils can be added to the above

benefits, but is subject to Underwriters’ approval and additional premium loading.

Requested Effective Date (dd/mm/yy):

THIS AREA IS INTENTIONALLY BLANK

GBG Ind. App 042408 Page 2

STATEMENT OF HEALTH BY APPLICANT.

ALL QUESTIONS MUST BE COMPLETED. FAILURE TO INCLUDE ALL MATERIAL MEDICAL

INFORMATION OR PROVIDING FALSE INFORMATION MAY RESULT IN CANCELLATION OF

COVER OR DENIAL OF CLAIM PAYMENT AT TIME OF CLAIM.

ction 3

. Medical Questionnaire

(Part A)

If your answer is "Yes" to any of the following six questions please answer additional questions,

otherwise please move on to next question.

Does your state of health prevent you from performing your activity at full time?

Yes No

If yes, please answer following additional questions:

a) Partial or total sick leave:

b) Reasons of sick leave:

2) Have you suffered in the last 10 years from a disease or an accident entailing 30 days

or more sick leave and/or medical treatment?

Yes No

If yes, please answer following additional questions:

a) Cause and length of sick leave:

b) Date of sick leave:

3) Did you or are you planning to undergo a surgical operation?

Yes No

If yes, please answer following additional questions:

a) Which one?

b) When?

4) Do you suffer from any disabling illness, physical defect, infirmity or congenital illness

or from the consequences of an illness or accident?

Yes No

If yes, please answer following additional questions:

a) Which disablement?

b) Which ones?

c) Date of accident?

d) Wounds?

5) Do you receive any disability pension or work accident pension?

Yes No

If yes, please answer following additional questions:

a) Why?

GBG Ind. App 042408 Page 3

ction 3

. Medical Questionnaire

(Part B)

Have you been advised, counselled, tested, diagnosed, treated, hospitalized, or recommended for treatment

within the last 10 years for the following:

(If you answer “Yes” to any question, please circle the condition to which you are referring and give complete details in Part C.)

1) Seizures or seizure disorder; paralysis; multiple sclerosis; or any disorder of the central

nervous system?

Yes No

2) Mental retardation; any mental, behavioural, emotional, or eating disorder; anxiety,

depression, neurosis or psychosis; psycho-therapy; psychological, marital or any form of

counselling or therapy?

Yes No

3) High blood pressure; heart attack; stroke; chest pain or palpitations; murmur; varicose

veins, blood clot, anaemia, or any other blood, heart, or circulatory disorder or condition?

Yes No

4) Asthma; emphysema; bronchitis; sinusitis; pneumonia; allergies; apnea; or any breathing

difficulty, lung or respiratory disease, disorder or condition?

Yes No

5) Colitis; chronic diarrhoea or intestinal problems; hernia; ulcer of the stomach or

duodenum; haemorrhoids or rectal disorder; hepatitis or liver disorder; gallbladder,

pancreas, oesophagus, or any other digestive disorder or condition?

Yes No

6) Cancer, tumour, growth, cyst, enlarged lymph nodes; psoriasis, keratosis, lesions of the

skin or mouth, or any other skin disorder?

Yes No

7) Disease or disorder of the breast; kidney; kidney stones; bladder; prostrate; abnormal

PSA, or any other urinary disorder or infection?

Yes No

8) Disease or disorder of the genital or reproductive system; herpes, any sexually disease;

endometriosis, or abnormal pap smear?

Yes No

9) Been treated for infertility; taken any medication, or advised to seek treatment, medication,

diagnostic tests or surgery for infertility?

Yes No

10) Arthritis; rheumatism; gout; TMJ (temporomandibular joint syndrome); any injury to or

disease or disorder of the spine, back, jaw, bones, muscles, or joints; joint replacement; or

chiropractic treatment?

Yes No

11) Pituitary, adrenal, or thyroid disorder; lupus; diabetes? Yes No

12) Cataracts; glaucoma; or any eye disorder; hearing loss; or any ear nose, or throat

disorder?

Yes No

13) Alcoholism; alcohol, drug or substance abuse or dependency? Yes No

14) Acquired immune Deficiency Syndrome (AIDS), AIDS-Related Complex (ARC), HIV

Positive, or other immune disorders?

Yes No

15) Have any parents, children, or siblings suffered from cancer, diabetes, hyperlipedemia,

chronic mental diseases before 50 years of age?

Yes No

16) Have you gained or lost more than 12 kilos or 25 pounds during the last 12 months? Yes No

17) Have you smoked cigarettes or used tobacco in any form in the past 12 months? Yes No

18) Have you ever been declined, postponed, rated, or limited for Life, Health, or Accident

Insurance?

Yes No

19) Have you been hospitalized in the last 10 years for any reason? Yes No

20) Do you engage in any profession, sport, or hobby that could be considered hazardous? Yes No

21) During the past 3 years, has any illness or injury prevented you from work? Yes No

22) During the past 5 years, have you consulted or been advised to consult a medical

practitioner for any significant physical impairment, deformity sickness, operation, injury,

or hospitalization other than revealed in questions above?

Yes No

GBG Ind. App 042408 Page 4

Section 3.

Medical Questionnaire

(Part C)

Give details of each item answered "Yes" in Part B.

(If more space is needed, attach separate page, which must be signed and dated)

Question

No.

Condition/

Diagnosis

Treatment

(Surgeries/

Medications)

Treatment

Dates from/to

Ongoing or

Date of

Recovery

Name, Location or Telephone Number of

Physician, Hospital/Institution

Section 4. MEDICAL PRACTITIONER

Please provide details of your family Doctor(s), if you have one:

Details of Current Family Doctor: Details of Previous Family Doctor, if changed within past 5 years:

Name: __________________________________

Mailing Address: __________________________________

__________________________________

Email: __________________________________

Telephone No.: __________________________________

Name: __________________________________

Mailing Address: __________________________________

__________________________________

Email: __________________________________

Telephone No.: __________________________________

Section 5. BENEFICIARY INFORMATION (APPLICABLE FOR LIFE COVER ONLY)

Please provide details of the beneficiary for any Life Insurance Benefit:

Is Beneficiary an Individual(s) or an Entity:



Individual(s)



Entity (Trust, Estate, Corporation or Partnership)

Name: ___________________________________________________ Telephone No.: ____________________________

Mailing Address: ________________________________________________________________________________________________

________________________________________________________________________________________________

Section 6. METHOD OF PAYMENT

Please tick

( )

Method of Payment



Check (Drawn on US Bank in US dollars)

Payable to: GBG

Holdings, Inc.

Send Payment to: GBG Holdings, Inc.

26000 Towne Centre Drive

Foothill Ranch, CA

92610



Wire Transfer (Sent in US dollars)

Send Payment to: Citibank, N.A.

6436 Irvine Blvd.

Irvine, CA 92620

Routing #: 322271724

For further credit to:GBG Holdings, Inc. Premium Account

Account #: 202559357

Swift Code: CITI US 33



Electronic Payment

(For US Banks and in US dollars)

Send Payment to: Citibank, N.A.

Routing No.:

322271724

Account No.: 202559357



Credit Card

Please visit www.tiecare.com and click on payment.

For Personal Assistance please call 888-824-6627

GBG Ind. App 042408 ?

Page 5

Section 7. REPRESENTATIONS, ACKNOWLEDGMENTS, AND AUTHORIZATIONS

I apply for coverage as indicated hereabove, for which I am or may become eligible under the agreement with Sagicor Capital Life

Insurance Co.; and/or GBG Insurance, Ltd.; and/or Lloyd's Underwriters, all as underwritten, and managed by Global Benefits Europe/

Global Benefits Group, Inc., and which is hereinafter called the Insurer.

The insurance plan shall be governed exclusively by the laws of Bermuda/Bahamas/Guernsey/U.K, as applicable.

I have been informed of the terms and conditions of the insurance plan. I accept these terms and conditions and declare that to the

best of my knowledge and belief the statements made in this Application form are true and complete. I understand that failure to

disclose information in this application may be the basis for cancellation of policy or claims denial.

I hereby declare that I am currently actively at work and mentally and physically capable of conducting the regular duties of m y

employment and have not been absent from work for more than 10 consecutive days in the preceding twelve months.

I agree that there shall be no insurance until this application has been accepted by the Insurer, and the first full premium has been paid,

and that payment has been effectively received by the Insurer.

I authorize any medical professional, hospital, clinic, other medical or medically related facility, governmental agency, or other person

or firm to provide the Insurer or their authorized representative information, including copies of records, concerning advice, care, or

treatment provided to me, including without limitation, information relating to mental illness or use of drugs or alcohol.

I understand that such information will be used by the Insurer for the purpose of evaluating my application for insurance, or by Insurer

representatives involved in evaluating, determining, or administering claims for insurance benefits for. I understand that I or any

authorized representative will receive a copy of this authorization upon request.

TieCare/GBG Representative:

(or broker name and contact

information, if applicable.)

EXPEDITING YOUR APPLICATION

We cannot accept your application if this Health Declaration is incomplete. Should we need to contact you rapidly regarding the Health

Declaration, please circle your preferred method and provide details:

Telephone / Private E-Mail / Other:

_____________________________________________________________________

Signature of Life to be Assured:

Date Signed:

Please use additional space below for any long answers you may have or additional information you may

think is necessary:

GBG Ind. App 042408

Page 6