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Please enter the name of the Policy Holder or if joining an Employer Policy the name of your Employer.
The name of the owner of the policy, this could be a family member or the name of your employer.
Please enter information of insured persons.
Are you currently covered by any medical insurance policy?
Please provide us with a scan copy of the policy and benefits schedule via email to inquiry@pacificcross.com
Has any medical or life application been declined, rated or restricted?
Has any medical or life policy been cancelled, withdrawn, rated or restricted?
speech defect, paralysis, hearing loss, physical defect, infirmity, congenital illness, genetic deformity or disease or chronic condition?
When was the initial onset of the condition and what was the exact diagnosis made by the doctor including any identified underlying cause?
What treatment, medication, test, surgery did you receive?
When and where was the last time you visited your doctor for this condition?
Do you currently have any on-going treatment for this condition? If yes, please provide the details.
What is the current status of this condition; are there any ongoing complications or limitations to your health from this condition?
asthma, respiratory or allergic condition or disorder of the eyes, ears, nose or throat?
What treatment/medication/test/surgery did you receive?
psychiatric or mental disorder, fainting, blackout, mood change, drug/alcohol addiction, seizure or fit?
hypertension, high/low blood pressure, chest pain, cholesterol problem, dizziness, heart or circulatory disorder?
kidney stone, venereal disease, or disorder of the bladder, prostate, kidney or genito-urinary tract?
hepatitis, ulcer, hemorrhoid, colitis or stomach, gall bladder, liver or bowel disorder?
sciatica, back pain, joint pain or rheumatic, arthritic, muscle, joint or bone disease or disorder?
blood abnormality or blood vessel disorder?
HIV, AIDS, AIDS Related Complex, or any indication of blood or immune system disorder?
cancer, tumor or cyst?
skin disorder?
diabetes mellitus, glandular or hormonal disorder?
rheumatic fever, gout, malaria or hernia of any kind?
gynecological disorder or disease or complication associated with pregnancy?
any other ailment, impairment, or injury?
Are you currently undergoing any investigations or taking any medications or receiving any form of treatment recommended or prescribed?
please provide further information related to treatment including any medication you are currently taking (list with dosage)
Have you been a patient in a hospital or sanitarium for surgery, observation or treatment in the last 5 years?
please provide further information
Have you ever smoked or otherwise used tobacco?
Please advise the consumption (pack) and duration of tobacco use
Personal Physician Information (optional)
Personal Accident Benefits pays out a lump sum to a beneficiary in the event of death or Permanent Disability due to an Accident. For more information on what is covered please refer to the Policy Wording Document?
{PersonalBenefitAmount1864:description}
{PersonalBenefitAmountUnder18:description}
{PersonalBenefitAmount6574:description}
Note: you can select more than one discount, upgrade and benefit.
Discount Options
TAL: limits coverage in North America, Japan, Singapore and Hong Kong (25% cheaper)
20% Co- Pay: you pay 20% and we pay 80% of eligible claims - 25% cheaper
Inpatient Only Cover: limits cover to Hospitalization and Emergency Room ONLY -25% cheaper
Upgrade Benefits
$500,000 USD Benefit: Upgrade to $500,000 USD overall benefit
Optional Benefits
Dental: $2,000 USD benefit with a 20% co-pay
Travel Benefit: Travel Insurance for outside your country of residence
Rental Car Protection: $10,000 USD benefit for loss or damage to rental car
Private Room: Upgrade to Private Room benefit worldwide
$2,000,000 USD Benefit: Upgrade to $2,000,000 USD overall benefit
Vision: $500 USD benefit with 20% co-pay
TAL: limits coverage in North America, Japan, Singapore and Hong Kong (20% cheaper)
20% Co- Pay: you pay 20% and we pay 80% of eligible claims 20% cheaper
$3,000,000 USD Benefit: Upgrade to $3,000,000 USD overall benefit
$1,000 yearly deductible: you pay first $1,000 of eligible expenses per year (included)
$2,500 yearly deductible: you pay first $2,500 of eligible expenses per year - 25% cheaper
$5,000 yearly deductible: you pay first $5,000 of eligible expenses per year -35% cheaper
$1,000,000 USD benefit: Upgrade to $1,000,000 USD overall benefit
$50,000 USD Surgeon Fee: Upgrade to $50,000 USD surgeon fee benefit
Room & Board (per US$50 increase)
Up to
I hereby apply for a policy to be based on the above statements and declare that, to the best of my knowledge and belief, all answers to the foregoing questions are correctly and accurately recorded, and that they are full, complete and true.
I hereby authorize any licensed physician, medical practitioner, hospital, clinic or other medical or medically related facility, insurance company or other organization, institution or person, that has any records or knowledge of me or my health, to give to PACIFIC CROSS INSURANCE COMPANY LIMITED any such information. A photostat copy of this authorization shall be as valid as the original.
Name of the person who completed the application
Broker Name or Number (if applicable)
Date of Application
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