Fillable Africa Wellness Solutions Switch Form (Page 3 of 4) in pdf

Data protection acts – collection and use of personal information

In order to process your application, the information provided above will be processed electronically. This form, along with any/all attachments,

will therefore be transferred to the Medical Department of JWS Africa Healthcare Services, whilst being compliant with medical secrecy.

As per the «data protection act» (in French law) dated 06 January 1978, subsequently modified by a law passed on 06 August 2004, you have the

right to access, correct, modify and delete your personal data by sending your request to: Allianz Worldwide Care - Informatique et libertés - Case

courrier 2514 - Tour Neptune - 20, place de Seine - 92086 Paris La Défense Cedex.

By signing this form you accept that it will be transferred to the Medical Department of JWS Africa Healthcare Services whilst being compliant

with medical secrecy.

Declaration

Please read the following declarations carefully and only sign below if you understand and accept them.

(a) I, the undersigned, hereby declare that the information provided as well as my replies to the questions above, for me and for any member of my

family named on this Switch Form, are true and accurate to the best of my knowledge, and that I have neither declared nor omitted to declare

anything that may mislead the Insurer, and understand that I may be penalized per the L.113-8 and 9 articles of the French Insurance Code in

case of false declaration, omissions or inexact replies.

(b) I confirm that I have read and understood the full definitions, benefits, exclusions and conditions of this policy including the details relating to

pre-existing conditions.

(c) I agree to waive any rights that I may have to medical secrecy/confidentiality in respect of my medical information and I consent to the fact that

Allianz Worldwide Care, if it considers it appropriate, will check statements concerning my health condition and will check with other healthcare

insurers, all statements concerning previous, or existing contracts applied for. I authorise all such practitioners, physicians, dentists, members of

medical professions, employees of hospitals and health authorities as well as medical facilities to provide relevant medical information relating to

me, if requested by Allianz Worldwide Care, its medical advisers, its appointed representatives, or to any third party expert(s) in case of disputes,

subject to any legal restrictions which may apply. I also make this statement for my co-insured dependants, including those who cannot assess

the meaning of this statement.

(d) I understand that:

•

this Switch Form is valid for three months from the date of completing and signing it;

•

I can withdraw my application in writing by letter, email or fax, within 30 days from the date I receive the full terms and conditions of my policy,

and provided that I have not submitted a claim, I am entitled to a full refund of the premium.

(e) I accept that:

•

it is my responsibility to check the accuracy of the information contained within the Certificate of Insurance, once issued. If the content is not in

accordance with the Switch Form, the situation will be considered accepted if I enter no protest within 30 days following the issue date of the

Certificate of Insurance;

•

this policy will be subject to the standard policy terms and conditions effective at the time of policy commencement contained within the

Membership Guide;

•

the cover provided by Allianz Worldwide Care, through JWS Africa Healthcare Services, may not be suitable if my dependants and I are or

become resident in countries where local compulsory health insurance restrictions are in place (e.g. Switzerland);

it is my responsibility to check whether I am subject to any local compulsory health insurance requirements, to ensure that my healthcare cover

•

is legally appropriate in my country of residence and I have satisfied myself that my insurance cover is legally appropriate.

(f) I hereby declare that my existing international health insurance policy, Policy Number: __________________ is currently in-force with the following

insurance company: _______________________ and that the terms offered by JWS Africa Healthcare Services are based on the premise that I have

at the point of application an in-force health insurance policy with the above declared insurance company. I accept that I am required to provide

a copy of my Insurance Certificate and proof that my existing international health insurance policy is paid up to date. I understand that claims

may be rejected if at the point of claim it is revealed that I did not have an in-force health insurance policy with the above declared insurer at the

point of applying to switch my cover to JWS Africa Healthcare Services, or where I failed to answer the questions on this declaration correctly. This

declaration is deemed to be part of the contract with JWS Africa Healthcare Services.

(g) I understand that I will be subject to full medical underwriting if I fail to fulfil any of the above terms or if the contract with my existing

international healthcare provider is cancelled more than 30 days before my coverage with JWS Africa Healthcare Services starts.

(h) I hereby authorise JWS Africa Healthcare Services to act for and behalf of all persons named in the form in relation to the administration of this

policy which may include the disclosure of sensitive medical information. This authorisation will remain in place until I provide a written request

to Allianz Worldwide Care to revoke it.

As the applicant, I sign this declaration and Switch Form for and on behalf of all persons included in this form.

Applicant’s signature

Date:

DD/MM/YYYY

Applicant’s printed name preceded by the handwritten words

For office use only - Agent details and stamp

“read and approved”.

Your policy documents

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Printed documents posted to me