AIB International Medical Plan

About you

The person who will hold the policy.

Name and identity

First name*

Middle name* I have no middle name

Surname*

Date of birth*

Sex*

Marital status*

Identification type*

Identification number*

Primary nationality*

Identity verification

Photograph of you holding your identification document* Take or upload a clear photo of yourself holding the document whose number you entered above. Your face and the document must both be visible.

Work

Employment status*

Employer / self-employed business Leave blank if unemployed or retired.

Contact

Email address*

Mobile telephone*

Home telephone

Height

Weight

Address

Residential address*

My mailing address is the same as my residential address

Choose your cover

Three choices decide the premium. Everything else on this form affects acceptance, not price.

Major medical maximum

Deductible

Area of coverage

When cover starts

Policy start date* Ages are taken at this date, so it changes the premium.

Eligible dependants

Spouse and children to be insured under this policy. Leave empty if you are applying alone.

No dependants added.

Coordination of Benefits

Other medical cover held by you or any dependant listed above.

Other medical insurance

Do you, or any dependant listed on this application, have other medical insurance coverage?

Politically exposed persons

Are you, or a close family member or associate, a politically exposed person – someone who holds or has held a senior public position, or a senior role in a state-owned body or international organisation?

Health information

Answer for yourself and every dependant listed. Please answer every question completely and accurately – your application is assessed on these answers.

Your physician

Name of the personal physician for all applicants*

Date and reason last consulted, if within the past 10 years If there has been no consultation in the past 10 years, you may enter “Not applicable”.

Treatment given or medication prescribed

Has the applicant or any dependant ever been tested for, treated for, or had any known indication of…

Current treatment

For female applicants and dependants

Your indicative premium

Calculated from the insurer’s rate table. It is not an offer of cover.

Working it out…

Declaration

I confirm that I am the person named as applicant and that the statements and answers in this application are complete, true and correctly recorded. I understand that a fraudulent statement, whether innocently made or not, will prevent cover taking effect or terminate it. I understand that no cover is effective until the policy has been issued and the premium paid as agreed, and that for the lifetime of this plan no benefit is available for any condition whose symptoms or signs presented before the effective date.

I agree to the declaration above*

I authorise any physician, clinic, insurance company or other organisation holding records about my health to release them to the Company or its representative, for underwriting, claims administration and the administration of cover. I understand that refusing this authorisation will result in my application being rejected.

I give this authorisation*

International Medical Insurance Plan