Full Medical Underwriting Form - hcigroupglobal.com

About you

Title

Name *

First

Last

What is your date of birth? *

What is your nationality? *

Where were you born?

What is your gender? *

Male
Female

What is your marital status? *

Married
Divorced
Single
Other

Please give details

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Metric / Imperial *

Are you based in an office? *

Yes
No

Do you undertake any manual labour? *

Yes
No

Please give details

Which country will you be living in? *

Your main address *

Address Line 1

Address Line 2

City

State / Province / Region

Postal Code

Country

Do you also live at another address? *

Yes
No

Your other address

Address Line 1

Address Line 2

City

State / Province / Region

Postal Code

Country

Which address should we send your policy documents to?

Your email *

Your phone number (including country code) *

Policy documents will be available to download from our App.

App Store

Google Play

Are you eligible for benefits from any Social Security or government plan or do you have any other medical insurance? *

Yes
No

Please give details including ID numbers

Would you like to cover other people on this policy? *

Yes
No

You can add your partner and any dependent children under 21, or under 25 if they're not married and in full-time education.

Your partner (if applicable)

Partner's name

First

Last

Partner's date of birth

Partner's nationality

Where was your partner born?

What is your partner's gender?

Male
Female

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Number of children to cover

Child 1

Child 2

Child 3

Child 4

Are any of your children full time students?

Yes
No

Who is a full time student?

Are any of your children eligible for benefits from any Social Security or government plan or do they have other medical insurance?

Yes
No

Please give details including ID numbers

Build your plan

Which plan suits your needs best? *

Compare plans

How much excess would you like to pay? *

£0 / €0 / $0
£170 / €210 / $250
£710 / €860 / $1,000
£1,400 / €1,700 / $2,000

How much excess would you like to pay? *

£170 / €210 / $250
£710 / €860 / $1,000

How much excess would you like to pay? *

£0 / €0 / $0
£170 / €210 / $250
£710 / €860 / $1,000

How much would you like to set your co-pay as? *

0%
10%
20%
30%

This is a fixed amount that you will pay at the time of receiving a covered service or medication.

What currency would you like your policy to be in? *

GBP (£)
EUR (€)
USD ($)

When would you like the cover to start? *

Types of underwriting

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Full Medical Underwriting

Full Medical Underwriting may be a good option for you if you’re totally free from any pre-existing medical conditions or you have some that you don’t want to be covered for.

We ask you a few extra questions and depending on your answers, we can exclude certain conditions meaning you won’t be able to claim on them but this will give you a 10% discount for life. You can always ask us to review your exclusions if your health changes.

CPME

Continued personal medical exclusions may be a suitable option if you already have a health insurance plan in place and are looking for alternative cover whilst retaining your existing level of benefits.

Moratorium

Moratorium underwriting doesn’t cover any medical conditions you’ve had in the last two years (five years for cardiac or cancer conditions) before your policy begins. But you will be covered for these conditions if you don’t experience symptoms or need treatment, consultations, advice, medication or a special diet after two years of continuous cover with us (five years for cardiac or cancer conditions). This time is known as the ‘Moratorium waiting period’.

We don’t class routine check-ups as active treatment so if you’re confident that you won’t need treatment for a pre-existing condition within the next two years.

Moratorium may be the right cover for you but it’s worth bearing in mind that you won’t get any premium discounts with this type of underwriting.

Choose your underwriting *

Full Medical Underwriting
CPME
Moratorium

Your health

1. Does anyone on this plan have any physical defect or infirmity? *

Yes
No

2. Has anyone suffered from any recurring illness or injury or taken prescribed drugs regularly? *

Yes
No

3. Has anyone had a surgical operation in the last five years for cancer or heart disease or is it likely that they’ll have one in the future? *

Yes
No

4. Has anyone seen a doctor in the last two years or will need to in the near future? *

Yes
No

5. Does anyone play any dangerous sports or activities? *

Yes
No

Full Medical Underwriting questions

Do you smoke or use tobacco products? *

Yes
No

Has anyone been advised, counselled, tested, diagnosed, treated, hospitalised or recommended for treatment in the last 10 years for the following:

6. Seizures or seizure disorder, paralysis, multiple sclerosis or any disorder of the central nervous system *

Yes
No

Neurology medical questionnaire

Which policyholder(s) have experienced seizures or seizure disorder, paralysis, multiple sclerosis or any disorder of the central nervous system?

6.1 Symptoms / diagnosis

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6.4 Are you currently experiencing any symptoms?

Yes
No

6.5 Are you performing activities of daily living (bathing, dressing, eating etc) with:

Little or no difficulty
Moderate difficulty
Extreme difficulty

6.6 What degree of muscle strength do you have?

Little or no difficulty
Moderate difficulty
Complete loss

6.7 What degree of bladder / bowel function do you have?

Little or no difficulty
Partial loss
Complete loss

If you have difficulties, please give details

6.8 Have you ever had problems with:

If you have had problems, please give details

6.9 Are you taking any medication?

Yes
No

Medication details

Please provide details of any further medication if applicable

6.10 Have you had a CT Scan

Yes
No

Date of latest CT scan

Results of latest CT scan

6.11 Have you had a MRI scan?

Yes
No

Date of latest MRI scan

Results of latest MRI scan

6.12 Have you had any other tests other than a CT scan / MRI scan?

Yes
No

Please provide the type of test(s), the date(s) and the result(s).

6.13 Have you ever been hospitalised for a neurology condition?

Yes
No

Please give dates and details

6.14 Are you currently under any other treatment not yet mentioned?

Yes
No

Please give details

7. Mental retardation, any mental, behavioural, emotional or eating disorder, anxiety, depression, neurosis or psychosis, psychotherapy, psychological, marital or any type of counselling or therapy *

Yes
No

Mental Health Medical Questionnaire

Which policyholder(s) have experienced mental retardation, any mental, behavioural, emotional or eating disorder, anxiety, depression, neurosis or psychosis, psychotherapy, psychological, marital or any type of counselling or therapy?

7.1 On what date did you first consult a physician?

7.2 What diagnosis was made?

7.3 How frequent are the symptoms? (state number per month /year)

7.4 What was the date of the most recent episode of symptoms?

7.5 Are you taking any medication?

Yes
No

List medication name(s), dosage and frequency

7.6 Who has prescribed this medication?

7.7 Give details of any limitations in daily activities you currently have as a result of your coondition

7.8 Has there been any time lost from work due to this condition?

Yes
No

Please give dates and details

7.9 Has there been any hospital treatment or referral to a Psychiatrist?

Yes
No

Please give dates and details

7.10 Are you or have you ever received psychotherapy / counselling?

Yes
No

Please provide details

7.11 Was / is this condition triggered by any particular factor?

Yes
No

Please provide details

7.12 Have you ever received electro-convulsive therapy?

Yes
No

Please provide details

7.13 Have you ever tried to take your own life?

Yes
No

Please say when and provide details

7.14 Are you fully recovered from this condition?

Yes
No

Please confirm date of discharge from follow up

8. 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

Cardiology questionnaire

8.1 Has anyone to be covered on the policy ever had symptoms or been diagnosed with any type of heart disorder or cardiovascular disease?

Yes
No

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8.2 Have any of the following tests been completed?

Have any policyholders had a Thalium Stress ECG test?

Yes
No

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Have any policyholders had a Stress Echocardiogram?

Yes
No

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Have any policyholders had a Coronary Angiography?

Yes
No

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Have any policyholders had an Echocardiogram?

Yes
No

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Have any policyholders had a Chest X-Ray?

Yes
No

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Other tests not listed here

Please provide details of the test(s), the date(s) and the result(s).

8.3 Do you exercise on a regular basis?

Yes
No

8.4 Have any policyholders ever been diagnosed with any of the following?

Abnormal lipid levels

Yes
No

Details

Elevated homocysteine

Yes
No

Details

Diabetes

Yes
No

Details

High blood pressure

Yes
No

Details

Peripheral Vascular Disease

Yes
No

Details

Irregular heartbeat

Yes
No

Details

Cancer

Yes
No

Details

Overweight

Yes
No

Details

Elevated cholesterol

Yes
No

Details

Date of last cholesterol test

HDL / total cholesterol ratio

Cerebrovascular or carotid disease

Yes
No

Details

8.5 Have any policyholders had bypass or stenting surgery?

Yes
No

Number of vessels by-passed

How badly were the vessels occluded?

Please give a percentage.

Has a follow up stress exercise ECG been completed since the procedure?

No
Yes - normal result
Yes - abnormal result

Date of test

Has there been any chest discomfort since the procedure?

Yes
No

Please provide details

Is any policyholder taking medication?

Yes
No

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9. Asthma, emphysema, bronchitis, sinusitis, pneumonia, allergies, apnea or any breathing difficulty, lung or respiratory disease, disorder or condition *

Yes
No

Respiratory medical questionnaire

How many policyholders have respiratory medical issues?

9.1 What is the diagnosis?

9.1 Additional policyholder: Name and diagnosis?

9.2 When was the condition first diagnosed?

9.2 Additional policyholder: When was the condition first diagnosed?

9.3 How frequent are the symptoms? (state number per month/year)

9.3 Additional policyholder: How frequent are the symptoms? (state number per month/year)

9.4 How disabling are the attacks? To what extent are your normal activities limited by an attack?

9.4 Additional policyholder: How disabling are the attacks? To what extent are your normal activities limited by an attack?

9.5 When was the most recent episode of symptoms?

9.5 Additional policyholder: When was the most recent episode of symptoms?

9.6 Are the symptoms seasonal or throughout the year?

9.6 Additional policyholder: Are the symptoms seasonal or throughout the year?

9.7 Has there ever been hospitalisation for this condition?

Yes
No

9.7 Additional policyholder: Has there ever been hospitalisation for this condition?

Yes
No

Please give dates and details

9.8 Is any medication being taken? (including inhalants?)

Yes
No

9.8 Additional policyholder: Is any medication being taken? (including inhalants?)

Yes
No

Please list names, dosage and frequency

Additional policyholder: Please list names, dosage and frequency

9.9 Are the symptoms

9.9 Additional policyholder: Are the symptoms

9.10 Have steroids (eg prednisolone) ever been prescribed?

Yes
No

9.10 Additional policyholder: Have steroids (eg prednisolone) ever been prescribed?

Yes
No

Please provide details

Additional policyholder: Please provide details

9.11 What were the dates and results of your last pulmonary function test, chest xray or allergy test?

9.11 Additional policyholder: What were the dates and results of your last pulmonary function test, chest x-ray or allergy test?

9.12 How often are you being followed up and by whom?

9.12 Additional policyholder: How often are you being followed up and by whom?

9.13 Has there been any time lost from work due to this condition?

Yes
No

9.13 Additional policyholder: Has there been any time lost from work due to this condition?

Yes
No

Please give dates and details

9.14 Please give details of your smoking habits before and after diagnosis

9.14 Additional policyholder: Please give details of your smoking habits before and after diagnosis

9.15 If any further policyholders have respiratory medical issues please provide full details here

10. 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

Gastroenterology medical questionnaire

How many policyholders have gastroenterology medical issues?

10.1 Diagnosis

eg dudenal/gastric ulcer, Crohn's, ulcerative colitis

10.1 Additional policyholder: Name and diagnosis

eg dudenal/gastric ulcer, Crohn's, ulcerative colitis

10.2 Date of diagnosis

10.2 Additional policyholder: Date of diagnosis

10.3 How frequent are the symptoms?

State the average number per month / per year

10.3 Additional policyholder: How frequent are the symptoms?

State the average number per month / per year

10.4 When was the most recent episode of symptoms?

10.4 Additional policyholder: When was the most recent episode of symptoms?

10.5 Have you ever had signs of bleeding or any other symptoms from the problem? (eg anaemia, blood in stool or vomit etc)

Yes
No

10.5 Additional policyholder: Has there been signs of bleeding or any other symptoms from the problem? (eg anaemia, blood in stool or vomit etc)

Yes
No

Please provide dates and details

10.6 Have you had any investigations or tests or do you have any planned?

Yes
No

10.6 Additional policyholder: Has there been any investigations or tests or are any planned?

Yes
No

Please give details, dates and the results

10.7 Have you ever had or are you awaiting any surgery for the problem?

Yes
No

10.7 Additional policyholder: Has there ever been are you awaiting any surgery for the problem?

Yes
No

Please provide dates and details of the surgical procedure(s)

10.8 Have you taken medications in the past?

Yes
No

10.8 Additional policyholder: Have medications been taken in the past?

Yes
No

Please list the name(s), dosage and frequency of medication taken

10.9 Are you taking any medications now?

Yes
No

10.9 Additional policyholder: Are any medications being taken now?

Yes
No

Please list the name(s), dosage and frequency of medication taken

10.10 Do you require other types of treatment such as dietary modifications?

Yes
No

10.10 Additional policyholder: Are other types of treatment such as dietary modifications required?

Yes
No

Please give dates and details

10.11 Has there been any hospitalisation or time lost from work due to this condition?

Yes
No

10.11 Additional policyholder: Has there been any hospitalisation or time lost from work due to this condition?

Yes
No

Please give dates and details

10.12 Are you fully recovered from this condition?

Yes
No

10.12 Additional policyholder: Are they fully recovered from this condition?

Yes
No

Please confirm date of discharge from follow up

Additional policyholder: Please confirm date of discharge from follow up

10.13 If any further policyholders have gastroenterology issues please provide full details here

11. Cancer, tumour, growth, cyst, enlarged lump nodes, psoriasis, keratosis, lesions of the skin or mouth, or any other skin disorder *

Yes
No

Cancer Medical Questionnaire

How many policyholders are affected?

11.1 Name of the cancer and the location

11.1 Additional policyholder: Name of the cancer and the location

11.2 Date of diagnosis

11.2 Additional policyholder: Date of diagnosis

11.3 State and grade of cancer

11.3 Additional policyholder: State and grade of cancer

11.4 What symptoms did you have prior to your diagnosis?

11.4 Additional policyholder: What were the symptoms prior to diagnosis?

11.5 Number of lymph nodes involved

11.5 Additional policyholder: Number of lymph nodes involved

11.6 How was your cancer treated?

11.6 Additional policyholder: How was the cancer treated?

Please give further details of treatment eg chemotherapy regime and medication name

Additional policyholder: Please give further details of treatment eg chemotherapy regime and medication name

Duration of treatment

Additional policyholder: Duration of treatment

Date of last treatment

Additional policyholder: Date of last treatment

11.7 Was there any indication of the cancer spreading?

Yes
No

11.7 Additional policyholder: Was there any indication of the cancer spreading?

Yes
No

Please provide details including location(s)

Additional policyholder: Please provide details including location(s)

11.8 Has there been any evidence of recurrence?

Yes
No

11.8 Additional policyholder: Has there been any evidence of recurrence?

Yes
No

Please provide details

11.9 Is there any family history of cancer?

Yes
No

Please provide details

11.10 Are you currently on any medication / treatment?

Yes
No

11.10 Additional policyholder: Are you currently on any medication / treatment?

Yes
No

Please provide names and dosage

Additional policyholder: Please provide names and dosage

11.11 Date you last consulted your physician

11.11 Additional policyholder: Date you last consulted your physician

11.12 If any further policyholders have experienced cancer or related issues please provide full details here

12. Disease or disorder of the breast, kidney, kidney stones, bladder, prostate, abnormal PSA or any other urinary disorder or infection *

Yes
No

Urology medical questionnaire

How many policyholders are affected?

12.1 When did the symptoms first occur / original start date of condition

12.1 Additional policyholder: When did the symptoms first occur / original start date of condition

12.2 What diagnosis was made?

12.2 Additional policyholder: What diagnosis was made?

12.3 What were the first symptoms?

12.3 Additional policyholder: What were the first symptoms?

12.4 Select if any of these conditions are present

12.4 Additional policyholder: Select if any of these conditions are present

Please specify

12.5 Date of last urine analysis, kidney function, PSA test

12.5 Additional policyholder: Date of last urine analysis, kidney function, PSA test

Result

Additional policyholder: Result

12.6 Have any of the following occurred?

12.6 Additional policyholder: Have any of the following occurred?

12.7 Have you ever had blood in your urine?

Yes
No

12.7 Additional policyholder: Have you ever had blood in your urine?

Yes
No

Please give details and dates

12.8 Have you ever had kidney stones?

Yes
No

12.8 Additional policyholder: Have you ever had kidney stones?

Yes
No

How were they treated?

Additional policyholder: How were they treated?

12.9 Have you ever been diagnosed as having kidney failure?

Yes
No

12.9 Additional policyholder: Have you ever been diagnosed as having kidney failure?

Yes
No

Please give details and dates

12.10 Have you ever needed dialysis?

Yes
No

12.10 Additional policyholder: Have you ever needed dialysis?

Yes
No

Please give details and dates

12.11 Have you ever been diagnosed with renal (kidney) cancer?

Yes
No

12.11 Additional policyholder: Have you ever been diagnosed with renal (kidney) cancer?

Yes
No

Please give details and dates

12.12 Do you have any tests pending?

Yes
No

12.12 Additional policyholder: Do you have any tests pending?

Yes
No

Please give details and dates

12.13 Are any policyholders currently on any medication or having any treatment?

Yes
No

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12.14 Have you ever been hospitalised for this condition?

Yes
No

12.14 Additional policyholder: Have you ever been hospitalised for this condition?

Yes
No

Please give details and dates

12.15 Have you ever required emergency treatment for this condition?

Yes
No

12.15 Additional policyholder: Have you ever required emergency treatment for this condition?

Yes
No

Please give details and dates

12.16 If any further policyholders have urology related issues please provide full details here

13. Disease or disorder of the genital or reproductive system, herpes, any sexually transmitted disease, endometriosis, or abnormal pap smear *

Yes
No

Sexually transmitted infections medical questionnaire

How many policyholders are affected?

13.1 When did the symptoms first occur or when was the condition first detected?

13.1 Additional policyholder: When did the symptoms first occur or when was the condition first detected?

13.2 What was the final diagnosis?

13.2 Additional policyholder: What was the final diagnosis?

13.3 Are you currently experiencing any symptoms?

Yes
No

13.3 Additional policyholder: Are you currently experiencing any symptoms?

Yes
No

When did you last have symptoms?

13.4 Does anyone to be covered on the policy have any tests pending?

Yes
No

Please give dates and details

13.5 Has anyone to be covered required any procudures or other treatment for their condition?

Yes
No

Please give dates and details

13.6 Were any follow up visits recommended?

Yes
No

Please give dates and details

13.7 Has anyone been hospitalised for this condition?

Yes
No

Please give dates and details

13.8 Is anyone currently taking any medication for this?

Yes
No

Please give dates and details

13.9 Is anyone currently receiving any other treatment not yet mentioned?

Yes
No

Please give details

14. Been treated for infertility, taken any medication or been advised to get treatment, diagnostic tests or surgery for fertility *

Yes
No

15. 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

Musculoskeletal medical questionnaire

How many policyholders are affected?

15.1 What is your diagnosis?

15.1 Additional policyholder: What is your diagnosis?

15.2 When were you first diagnosed with this condition?

15.2 Additional policyholder: When were you first diagnosed with this condition?

15.3 How frequent and severe are the symptoms? (state average frequency per month / year)

15.3 Additional policyholder: How frequent and severe are the symptoms? (state average frequency per month / year)

15.4 Do any policyholders have joints affected?

Yes
No

Please specify

15.5 When was your most recent episode of symptoms?

15.5 Additional policyholder: When was your most recent episode of symptoms?

15.6 Have any policyholders ever received physical therapy or had surgery as a result of their condition, or is any planned?

Yes
No

Please give dates and details

15.7 List any limitations in daily activities or any type of physical limitations you currently have from your condition

15.7 Additional policyholder: List any limitations in daily activities or any type of physical limitations you currently have from your condition

15.8 Are any policyholders taking any medication?

Yes
No

Please list name(s), dosage, frequency and who is taking it

15.9 Has any policyholder been hospitalised or had time lost from work due to this condition?

Yes
No

Please give dates and details

15.10 Are you fully recovered from this condition?

Yes
No

15.10 Additional policyholder: Are you fully recovered from this condition?

Yes
No

Please confirm date of discharge from follow up

Additional policyholder: Please confirm date of discharge from follow up

Additional policyholder: Please provide details of ongoing care or follow ups

15.11 If any further policyholders are affected by musculoskeletal issues please provide full details here

16. Pituitary, adrenal or thyroid disorder, lupus, diabetes *

Yes
No

How many policyholders are affected?

16.1 When did the symptoms first occur / original start date of condition

16.1 Additional policyholder: When did the symptoms first occur / original start date of condition

16.2 What diagnosis was made?

16.2 Additional policyholder: What diagnosis was made?

16.3 Do you have a goiter?

Yes
No

16.3 Additional policyholder: Do you have a goiter?

Yes
No

Please confirm what type this is? (if known)

Additional policyholder: Please confirm what type this is? (if known)

16.4 Has anyone had, or is awaiting any surgery for this condition?

Yes
No

Please give dates and details of the surgical procedure

16.5 Has anyone ever had any diagnostic tests / biopsies for this condition or are any planned?

Yes
No

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16.6 Please provide details of any past medication or treatment

Please specify which policyholder and include medication / treatment, dosage and frequency.

16.7 What symptoms do you have now?

16.7 Additional policyholder: What symptoms do you have now?

16.8 Is anyone taking any medication now?

Yes
No

Please list the policyholder(s), medication name, dosage and frequency

16.9 How often are you being followed up and by whom?

16.9 Additional policyholder: How often are you being followed up and by whom?

16.10 Has anyone had any complications or has there been any hospitalisation for this condition?

Yes
No

Please provide dates and details

16.11 Are any future tests or treatments planned?

Yes
No

Please provide dates and details

16.12 If any further policyholders are affected please provide full details here

17. Cataracts, glaucoma, other eye disorder, hearing loss, or any ear, nose or throat disorder *

Yes
No

How many policyholders are affected?

17.1 When did the symptoms first occur / original start date of condition

17.1 Additional policyholder: When did the symptoms first occur / original start date of condition

17.2 What diagnosis was made?

17.2 Additional policyholder: What diagnosis was made?

17.3 Are you currently experiencing any symptoms?

Yes
No

17.3 Additional policyholder: Are you currently experiencing any symptoms?

Yes
No

When did you last have symptoms?

Additional policyholder: When did you last have symptoms?

17.4 How often do symptoms occur and how long do they last?

17.4 Additional policyholder: How often do symptoms occur and how long do they last?

17.5 Have you ever had diagnostic tests / biopsies for this condition?

Yes
No

17.5 Additional policyholder: Have you ever had diagnostic tests / biopsies for this condition?

Yes
No

Please provide details (diagnostic test, date performed and results)

Additional policyholder: Please provide details (diagnostic test, date performed and results)

17.6 Does anyone have any tests pending?

Yes
No

Please provide details and dates

17.7 Date of last medical consultation

17.7 Additional policyholder: Date of last medical consultation

17.8 Please provide details of any past medication or treatment

Include the policyholder, medication/treatment, dosage and frequency

17.9 Is anyone currently being treated?

Yes
No

Please give details

18. Alcoholism, alcohol, drug or substance abuse or dependency *

Yes
No

Please give details

Please state the policyholder(s), how long this has been an issue, how many units / substabces are consumed per week and details of any medical treatments or hospital admissions.

19. Acquired Immune Deficiency Syndrome (AIDS), AIDS-Related Complex (ARC), HIV Positive or other immune disorders *

Yes
No

Immune system disorders medical questionnaire

How many policyholders are affected?

19.1 When did symptoms first occur / original start date of condition

19.1 Additional policyholder: When did symptoms first occur / original start date of condition

19.2 What diagnosis was made?

19.2 Additional policyholder: What diagnosis was made?

19.3 Are you currently experiencing any symptoms?

Yes
No

19.3 Additional policyholder: Are you currently experiencing any symptoms?

Yes
No

When did you last have symptoms?

Additional policyholder: When did you last have symptoms?

19.4 How often do symptoms occur and how long do they last?

19.4 Additional policyholder: How often do symptoms occur and how long do they last?

19.5 Please list any diagnostic tests anyone has had carried out for this condition

Include the policyholder(s), test, date performed and the results.

19.6 Does anyone have any tests pending?

Yes
No

Please give details and dates

19.7 Date of last medical consultation

19.7 Additional policyholder: Date of last medical consultation

19.8 Please provide details of past treatment

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19.9 Has anyone ever been hospitalised for this condition?

Yes
No

Please give dates and details

19.10 Has anyone ever required emergency treatment for this condition?

Yes
No

Please give dates and details

19.11 Is anyone currently being treated for this condition?

Yes
No

Please provide details of all treatments / medications

19.12 If any further policyholders are affected please provide full details

20. Physical defect, infirmity or congenital illness *

Yes
No

Please give details

Please state the condition, the policyholder affected, symptoms and any treatment past or present.

21. Prosthesis, implant, monitoring device or internal fixation (ie. pins, plates or screws) *

Yes
No

Please give details

Please state the condition, the policyholder affected, symptoms and any treatment past or present.

22. During the past three years, has an illness or injury stopped anyone from working? *

Yes
No

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23. During the past five years, has anyone been told to go to a doctor for any significant physical impairment, deformity, sickness, operation, injury or hospital visit not mentioned above? *

Yes
No

Impairment

24. Has anyone suffered from cancer, diabetes, hyperlipidemia, chronic mental diseases before turning 50? *

Yes
No

Cancer, diabetes

25. Has anyone used drugs not prescribed by a doctor other than over-the-counter medications? *

Yes
No

Drugs

26. Has anyone been prescribed or taken any medication for a disease, disorder, condition, injury or counselling in the last 12 months? *

Yes
No

Conditions

27. Is anyone currently taking drugs or medication? *

Yes
No

Drugs or medications

28. Has anyone gained or lost more than 12 kilos (or 25 pounds) in the last 12 months? *

Yes
No

Weight

29. Is anyone waiting to have medical treatment, counselling or surgery? *

Yes
No

Treatment, counselling, surgery

30. Does anyone have any symptoms now that might cause a claim? *

Yes
No

Claim symptoms

31. Has anyone smoked cigarettes or used tobacco in the last 12 months? *

Yes
No

32. Has anyone been declined, postponed, rated or limited for Life, Health or Accident Insurance? *

Yes
No

Declined

33. Has anyone been hospitalised in the last 10 years for any reason? *

Yes
No

Hospitalised

34. Is anyone currently pregnant? *

Yes
No

Who is pregnant and when is the baby due?

35. Has anyone had any major dental treatment in the last five years such as dental surgery, periodontal treatment or crowns, bridgework or dentures? *

Yes
No

Past dental treatment

36. Is anyone thinking about having dental treatment? *

Yes
No

Future dental treatment

Your family doctor (if applicable)

Name *

First

Last

Email *

Phone

Address

Address Line 1

Address Line 2

City

State

Zip Code

Please upload a scan of your passport

Click or drag a file to this area to upload.

Please upload a JPEG, PNG or PDF file of your passport.

Your declaration

I understand that this policy is designed to cover expatriates and, as I live outside my normal home country, I consider myself to be eligible for the cover. I’m applying for an annual insurance policy and I agree that if I pay the premium by instalments and then cancel my plan during the policy period, I may still need to pay the remaining premium. I confirm that all the information I’ve given is true and complete to the best of my knowledge.I understand that my plan may be cancelled or my claims denied if I don’t disclose my information. I’ve read and agree to the terms and conditions of the insurance plan and understand that I won’t be covered until my application is accepted and HCI has received my premium.

I authorise any medical professional, hospital, clinic, facility, government agency, insurance company, other person or firm to give HCI and their authorised representatives information including copies of records of advice or treatment given to me and/or my dependants. This includes information about medical and mental illness or drug or
alcohol use.

I understand that HCI will use this information to evaluate my application and any claims I may make. I understand that if I’m not happy after I’ve received a certificate of insurance and associated documents, I can cancel this application and receive a full refund of the premium I’ve paid as long as I have not submitted a claim or used the policy for a visa application.

I agree to then send back these documents within 14 days. I authorise you to charge my card account unspecified amounts for my annual HCI health insurance plan as and when the premiums are due until I let you know in writing. I understand that you’ll tell me my renewal premium at least four weeks before my renewal date.

I have read and agree to the terms *

Yes

Protector Plans Application Form

About you

Your partner (if applicable)

Build your plan

Types of underwriting

Full Medical Underwriting

CPME

Moratorium

Your health

Full Medical Underwriting questions

Has anyone been advised, counselled, tested, diagnosed, treated, hospitalised or recommended for treatment in the last 10 years for the following:

Neurology medical questionnaire

Mental Health Medical Questionnaire

Cardiology questionnaire

Policyholder

Date of onset

Treatment

Current status

8.2 Have any of the following tests been completed?

8.4 Have any policyholders ever been diagnosed with any of the following?

Respiratory medical questionnaire

Gastroenterology medical questionnaire

Cancer Medical Questionnaire

Urology medical questionnaire

Sexually transmitted infections medical questionnaire

Musculoskeletal medical questionnaire

Immune system disorders medical questionnaire

Your family doctor (if applicable)

Your declaration