Dental Plan Application Form

Dental Plan Application Form
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29/F, BEA Tower, Millennium City 5, 418 Kwun Tong Road,
Kwun Tong, Kowloon, Hong Kong
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www.bluecross.com.hk
Please complete this form in BLOCK letters and if applicable, return together with a crossed cheque payable to: Blue Cross (Asia-Pacific) Insurance Limited.
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Name of Applicant (Surname/First Name) Date of Birth (dd/mm/yy) HKID Card/Passport No.
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Correspondence Address
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Place of Residence of the Insured Person
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Hong Kong
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Average stay of the Insured Person in HK per year
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Medical Claim Autopay A/C No.* Name of Bank Account Holder Bank Name Branch Name
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Mobile Phone
Home Tel.
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Office Tel.
Personal E-mail Address
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Bank Code Branch Code Account No.
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*The autopay A/C No. shall apply to all family members. Only bank account with 15 digits or below is acceptable. =G !"#$%&'()*+,-./01234567 89:2;
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Insured Name of Insured(Surname / First Name) HKID Card/
Persons (Same as Bank Account - for claim purpose) Passport No.
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Sex
Date of Birth(dd/mm/yy)
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Relationship with Applicant
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Insured
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1. HK$350 HK$
2. HK$350 HK$
3. HK$350 HK$
* If your next birthday falls within the coming six months from the application date, the premium rate will be based on your
next age attained. Otherwise, it will be based on your current age. Policy effective date will be used to determine the age
attained if it is different from the application date.
# The policy shall become effective after the completion of the pre-insurance oral examination with a report issued by the
examining dentist. (Waiver or pre-insurance oral examination applies to child aged under 4.)
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I/WE, HEREBY DECLARE AND AGREE:
1. That the answers to all the above questions including all information and particulars given herein are accurate, true and complete and are given to the best of my/our knowledge and belief. I/We have not withheld any material information
and accept that this application and declaration shall form the basis of the contract between Blue Cross(Asia-Pacific) Insurance Limited (“the Company”) and me/us. I/We hereby acknowledge that failure to supply true and accurate
answers to this application or inform the Company of all material information about my/our application may render the Company unable to accept or process this application or the insurance policy void.
2. That the insurance coverage applied for shall only take effect when this application has been accepted by and the first premium has been paid to the Company.
3. That the Applicant shall have the authority to deal with, receive or request for information from the Company concerning the Insured(s) in relation to any claims or matters arising from the policy issued pursuant to this application. I/We
further agree that payment of any benefits hereunder to the Policyholder or Insured(s) by the Company in relation to all medical claims shall be credited to the bank account as specified in part (I) of this application or made by cheque in
the absence of such an account, which shall constitute a full discharge on the part of the Company in relation to such claims.
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Personal Information Collection Statement
I / We understand and agree that any personal information collected or held by the Company (whether contained herein or otherwise obtained) may be used, stored, disclosed or transferred (within or outside of Hong Kong) to any
individuals / organisations associated with the Company or any third party the Company may consider necessary including any other company carrying on insurance or reinsurance related business, any intermediary, claims
investigator, medical facilities, other service providers relevant to insurance business, professional advisor, government authority or industry association / federation for the purposes of: (1) processing of this application / request and
provision of insurance or financial related product or service or any addition, alteration, variations, cancellation or renewal or reinstatement of them; (2) any scope of insurance coverage, claim processing or investigation or analysis
and data matching; (3) promotion of financial products or services by the Company and its affiliated companies; (4) communicating with me/us/the insured or any relevant organisation/person as the Company considers appropriate;
and (5) meeting any disclosure requirements imposed by law or court orders or pursuant to guidelines issued by regulatory or other relevant authorities. I / We have the right to obtain access to and to request correction of any personal
information concerning myself/ourselves held by the Company. I/ We understand that if I/ we do not want my/ our personal information to be used for purpose (3) above, I/ we may notify the Company at any time. Such request(s) or
notice(s) can be made in writing to the Company's Corporate Data Protection Officer at 29th Floor, BEA Tower, Millennium City 5, 418 Kwun Tong Road, Kwun Tong, Kowloon, Hong Kong.
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Name of Cardholder (Surname / First Name) Expiry Date (mm/yy) Relationship with the Applicant (must be direct family member)
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Declaration:
1. I hereby authorise the Company to debit the premium and charge back ineligible
claim amounts from my credit card account specified herewith for the insurance
policy, until further written notice is given.
2. I understand that I have the right to cancel this authorisation at any time and
agree that any notice of cancellation or variation of this authorisation shall be
given to the Company and Credit Card Centre at least 1 month prior to the effective
date of such cancellation/variation.
3. I understand that all the personal information collected or held by the Company
may be used by or disclosed to any individual or organisation within or outside
Hong Kong for the purposes of assessing and servicing this application and
authorising direct debit payment or credit card payment. Any request(s) for access
to and correction of my personal information held by the Company can be made
in writing to the Company’s Corporate Data Protection Officer at 29/F, BEA Tower,
Millennium City 5, 418 Kwun Tong Road, Kwun Tong, Kowloon, Hong Kong.
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