Fillable Africa Wellness Solutions Switch Form (Page 2 of 4) in pdf

Dependants to be covered under the contract

Dependants can include your spouse/partner and any children financially dependent on the applicant under age 19, or under age 25 if in full-time

education. Where the child is 18 years of age or older, please attach a letter from the college/university confirming student status or a copy of the

student’s ID. We will consider adult dependants for cover aged under 75. If there is insufficient space for all dependants, please use another form.

Dependant 1

Dependant 2

Dependant 3

Dependant 4

Dependant 5

Relationship to applicant:

Spouse

Child

First name:

Surname:

Date of birth:

DD/MM/YYYY

Gender:

Male

Female

Male

Female

Male

Female

Male

Female

Male

Female

Occupation (mandatory); please

state if student:

Home country:

Principal country of residence:

Nationality:

Details of any current domestic or international health insurance

Name of insurer:

Policy number:

Commencement of cover

Please indicate the date you require cover from:

DD/MM/YYYY

Cover is conditional upon acceptance of your application, which is only confirmed when a Certificate of Insurance is issued to you.

Plan details (this section does not need to be completed if you are applying as part of a company group scheme.)

Please note that the plan chosen will apply to all policy members.

PRIMARY

ELITE

Africa and India

Worldwide excluding USA

Essential programme

Balanced programme

Optional Dental benefit^

Best programme

Best programme*

Optional Dental benefit^

^ Please note that if the main applicant applies for Dental benefit this applies to all applicants

* The optional Dental benefit is automatically included on the Elite Best Plan for Worldwide excluding USA.

DEDUCTIBLE OPTION (USD)

DEDUCTIBLE OPTION (GBP)

DEDUCTIBLE OPTION (EUR)

None

240

150

220

720

450

650

1440

900

1300

3200

2000

2900

Elective medical transfer benefit (for Elite only)

Where an insured person needs to undergo a major surgical intervention which does not constitute an emergency and can be planned, we will

arrange and pay for their transfer by economy class travel to their elected country; this does not need to be the nearest country but it must be

within their area of coverage.

This is a benefit where members can elect to go to another country if they feel uncomfortable having the treatment in the country in which they

are. The benefit can be utilized even if the procedure can be carried out within the country you are in, but it is only available in the event of a

non-emergency major surgical intervention. Please read the Membership Guide for the full meaning of “major surgical intervention.”

Example:

You may be on the ‘Worldwide excluding the USA’ area of coverage, and be residing in Kenya, and have a British passport. In the event of an

emergency situation you would most likely be taken to South Africa as the nearest country. In the event of a planned procedure you may want to

choose the UK, or another European Country as your “Elected Country”, and as long as you fulfil the criteria for “major surgical intervention”, we

would take you to your elected country and pay the air fare.

Please note that your Elected Country: 1. must be within your chosen geographical area of cover 2. will apply to all insured members of your

family 3. can be the same as your Home Country.

Please state your Elected Country:

Africa Wellness Solutions Switch Form Page 2

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