Health Protector Application

    Section 1-A: Applicant Details










    Section 1-B: Dependent Information Complete below only if enrolling dependents



    Children

    Others

    Section 1-C: Travel Pattern

    Anticipated travel pattern for the next 12 months. If applying for the War & Terrorism or Nuclear, Chemical, Biological perils extension, please provide details of security arrangements in place.

    Section 2-A: Medical Questionnaire Please complete for ALL members applying for coverage

    • Have you or any dependent been treated, diagnosed, tested, hospitalized, or recommended for treatment for any of the following?
      • Seizures or seizure disorder; paralysis: multiple sclerosis; or any disorder of the central nervous system?
      • Mental retardation; any mental, behavioural, emotional, or eating disorder; anxiety, depression, neurosis or psychosis; psychotherapy; psychological, or any form of counseling or therapy?
      • High blood pressure; heart attack, stroke, chest pain or palpitations, murmur, varicose veins, blood clot, anemia, or any other blood heart, or circulatory disorder or condition?
      • Asthma; emphysema; bronchitis; sinusitis; pneumonia; allergies; apnea; or any breathing difficulty, lung or respiratory disease, disorder or condition?
      • Colitis; chronic diarrhea, or intestinal problems; hernia; ulcer of the stomach or duodenum; hemorrhoids or rectal disorder; hepatitis or liver disorder; gallbladder, pancreas, esophagus, or any other digestive disorder or condition?
      • Cancer, tumor, growth, cyst, enlarged lymph nodes; psoriasis, keratosis, lesions of the skin or mouth or any other skin disorder?
      • Disease or disorder of the breast; kidney; kidney stones; bladder; prostate; abnormal PSA, or any other urinary disorder or infection?
      • Disease or disorder of the genital or reproductive system; herpes, any sexually transmitted disease; endometriosis, or abnormal pap smear?
      • Been treated for infertility; taken any medication, or advised to seek treatment, medication, diagnostic tests or surgery for infertility?
      • Arthritis; rheumatism; gout; TMJ (temporomandibular joint syndrome); any injury to or disease or disorder of the spine, back, jaw, bones, muscles, or joints; joint replacement?
      • Pituitary, adrenal, or thyroid disorder; lupus; diabetes?
      • Cataracts; glaucoma; or any eye disorder; hearing loss; or any ear, nose, or throat disorder?
      • Alcoholism; alcohol, drug or substance abuse or dependency?
      • Acquired Immune Deficiency Syndrome (AIDS), AIDS-Related Complex (ARC), HIV Positive, or other immune disorders?
    • Have you been advised to have a surgical procedure, hospitalization, or undergo testing that has not yet been completed?
    • Are you currently pregnant?
      • If yes, is there a history of complications with previous pregnancies or are complications anticipated with this pregnancy?
      • Is this pregnancy the result of infertility treatment?
    • Have you gained or lost more than 12 kilos or 25 pounds during the last 12 months?
    • Have you ever been declined, postponed, rated, or limited for Life, Health, or Accident Insurance?
    • Have you been hospitalized for any reason?
    • Have you undergone X-ray or MRI screening for any reason?
    • Have you consulted or been advised to consult a medical practitioner, or do you suffer from any significant physical impairment, deformity sickness, or injury other than revealed in questions above?
    • Do you engage in any profession, sport, or hobby that could be considered hazardous? Do you receive any disability pension or work accident pension?
    • Do you receive any disability pension or work accident pension?

    Section 2-B: Medical Questionnaire Give details of each item answered "Yes" in Section 2-A

    Section 2-C: Medication List all medications that are currently prescribed for you or a family member

    Section 3: Medical Practitioner Please provide details of your family Doctor, if you have one

    Section 4: Residence Verification Please complete Residence Verification Form for your dependents if residency is different from you

    I understand by signing this Application, that I, "სახელი გვარი" am certifying residing in the United States. I understand that I must notify Global Benefits Group / TieCare International immediately of any change in my and/or my dependents’ residency. Failure to do so may result in the denial of claims as well as recovery of any claims already paid.

    I will submit any address change directly to your main office located at: 26000 Towne Centre Drive, Suite 100, Foothill Ranch, CA 92610 USA. Phone: (949) 470-2100; Fax: (949) 457-3116; Email: enroll@gbg.com ; or to your European office located at: Bulevar Zorana Djindjica 81/VI/17, 11000 Belgrade, Serbia. Fax: +381 11 311 9888; Email: belgrade@gbg.com



    Section 5: Representations, Acknowledgements, and Authorizations

    I, the Undersigned Hereby:

    1. Declare that the foregoing answers to the best of my knowledge and belief are true and accurate and are offered as an inducement to grant insurance.
    2. Declare that I am currently actively at work and mentally and physically capable of conducting the regular duties of my employment and have not been absent from work for more than 10 consecutive days in the preceding twelve months.
    3. Agree that there shall be no insurance until the Insurer has approved this application.
    4. Authorize any medical professional, hospital, clinic, other medical or medically related facility, governmental agency, or other person or firm to provide the Insurer or their authorized representative information, including copies of records, concerning advice, care, or treatment provided to me, including without limitation, information relating to mental illness or use of drugs or alcohol.
    5. Understand that such information will be used by the Insurer for the purpose of evaluating my application for insurance, or by Insurer representatives involved in evaluating, determining, or administering claims for insurance benefits. I understand that any authorized representative or I will receive a copy of this authorization upon request.

    ANY CHANGES THAT OCCUR TO YOUR MEDICAL HISTORY PRIOR TO ISSUE OF THE POLICY MUST IMMEDIATELY BE REPORTED TO THE INSURER.



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