Uni-Care International Travel Insurance Service Crombie Lockwood (NZ) Limited Box 32167 Devonport Auck !

nd "7##$ New Ze! !nd %e & 6#'('##6 1166 )!x& 6#'('##* ++32 ,m!i & insure@uni-care.org Home

INBOUND MEDICAL DECLARATION

For submission b a!!licants "it# !re-e$istin% me&ical con&itions to &eclare' A((LICANT DETAILS Enter Titles) Names an& Dates o* Birt# o* a!!licants+-. D!te/ o. Birt0 !re not entered t0e po ic1 c!n not be i//ued Famil Name
2urn!me

,iven Names
)ir/t n!me/

,en&er

Birt# Date

3! e )em! e )orm!t& dd4mm41111

App ic!nt em!i !ddre// Cont!ct p0one number N!me o. educ!tion! in/titution or !5enc1$ i. !pp ic!b e6

MEDICAL DECLARATION 7 e!/e !n/wer t0e .o owin5 8ue/tion/& 16 9!ve 1ou been 0o/pit! i/ed in t0e !/t 12 mont0/: 26 Do 1ou /u..er .rom or 0!ve 1ou ever /u..ered .rom ! /eriou/ or i.e t0re!tenin5 medic! condition: 36 Durin5 t0e 6 mont0/ prior to t0i/ !pp ic!tion$ 0!ve 1ou /u..ered /ickne// or in<ur1 .or w0ic0 medic! tre!tment$ 0!/ been /ou50t$ 5iven$ recommended$ or .or w0ic0 ! re!/on!b e per/on wou d 0!ve /ou50t medic! !ttention:

No No No

;e/ ;e/ ;e/

#6 Are 1ou /u..erin5 .rom ! medic! condition$ i ne// or in<ur1$ inc udin5 /port/ re !ted in<urie/: *6 Are 1ou current 1 t!kin5 !n1 medic!tion:

No No

;e/ ;e/

)u in.orm!tion mu/t be provided be ow i. 1ou 0!ve !n/wered =;e/= to !n1 o. t0e !bove 8ue/tion/ ot0erwi/e proceed to t0e next /ection o. t0e !pp ic!tion6

Details o* Me&ical Con&ition-s.+ 7 e!/e enter per/on/ n!me !nd .u de/cription o. medic! condition/ 5ivin5 det!i / o. tre!tment$ medic!tion !nd w0et0er t0e condition i/ /t!b e or un/t!b e6

Name an& a&&ress o* &octor or s!ecialist+

Doctor tele!#one

Doctor *a$

(ersonal notes relatin% to our a!!lication

DECLARATION (7 e!/e re!d c!re.u 1)

16 ;ou 0!ve not been re.u/ed %r!ve -n/ur!nce b1 !n1 ot0er comp!n1 nor !re 1ou in/urin5 wit0 t0e intention o. receivin5 medic! tre!tment or to c !im .or event/ w0ic0 0!ve ! re!d1 occurred6 26 ;ou !re not !w!re o. !n1 circum/t!nce/ ike 1 to e!d to c!nce !tion or curt!i ment o. t0e trip6 %0e underwriter i/ !w!re o. ! .!ct/ ike 1 to !..ect t0e !ccept!nce or condition/ o. t0i/ in/ur!nce6 ;ou wi noti.1 t0e underwriter o. c0!n5e/ in circum/t!nce/ or 0e! t0 occurrin5 prior to 1our commencement d!te6 36 ;ou con.irm det!i / 0!ve been correct 1 dec !red in t0i/ !pp ic!tion .orm inc udin5 t0e 3edic! Certi.ic!te incorpor!ted in t0i/ document to be /ubmitted .or !pprov! b1 t0e underwriter6 #6 ;ou !5ree$ in t0e event o. i ne// or in<ur1 5ivin5 ri/e to c !im/ under t0e medic! /ection o. t0e po ic1$ to be medic! 1 ev!cu!ted to Au/tr! i!$ New Ze! !nd or 1our Countr1 o. >ri5in$ !/ !pp ic!b e$ !t t0e underwriter/ di/cretion6 *6 ;ou !5ree to ! w!iver o. priv!c1 in t0!t 1ou con/ent to !n1 re8ue/ted medic! in.orm!tion bein5 re e!/ed b1 1our doctor$ /peci! i/t$ or ot0er 0e! t0 provider to t0e ?nderwriter or it/ !5ent !nd to t0e re e!/e o. !n1 .urt0er in.orm!tion nece//!r1 .or t0e purpo/e/ o. t0i/ in/ur!nce6 66 ;ou !ut0ori/e !n1 c !im to be p!id to !n1 n!med in/titution w0ic0 0!/ /ubmitted c !im det!i / !nd re8ue/ted p!1ment to be m!de to t0em on 1our be0! .6 76 ;ou !ccept t0!t .!i ure to /upp 1 correct !pp ic!tion !nd medic! certi.ic!te det!i / m!1 !..ect t0e v! idit1 o. t0e po ic16 +6 ;ou 0!ve cert!in ri50t/ o. !cce// to !nd correction o. t0i/ in.orm!tion6 (6 ;ou under/t!nd t0!t t0i/ po ic1 doe/ not cover !n1 event$ w0ic0 0!ppen/ to 1ou un e// 1ou$ !t t0e d!te o. /uc0 event$ !re !5ed 6* 1e!r/ or under6 1"6 ;ou under/t!nd !nd !5ree t0!t t0e !ct o. tr!n/mittin5 t0i/ !pp ic!tion to ?ni'C!re$ b1 !ctiv!tin5 t0e =2ubmit App ic!tion= button on t0e web !pp ic!tion .orm$ wi 0!ve t0e e5! .orce o. ! /i5n!ture6 116 ;ou 0!ve re!d !nd under/tood !nd !ccepted t0e !bove /t!tement/ !nd !ccept re/pon/ibi it1 .or ! t0e in.orm!tion provided in t0i/ !pp ic!tion6 Declaration Bo$ ' %0e Dec !r!tion Box mu/t be c icked in order .or 1our !pp ic!tion to be /ubmitted6 A77L-CAN% 2%A%,3,N%& - 0!ve c icked in t0e Dec !r!tion Box !/ proo. o. t0e .!ct t0!t 0!ve re!d$ !5ree !nd !ccept p!r!5r!p0/ 1 to 11 o. t0e Dec !r!tion w0ic0 i/ ! compu /or1 e ement o. t0e ?ni'C!re on' ine !pp ic!tion .orm6