AXA Mansard Health Limited (RC 487419)

84b, Ozumba Mbadiwe Street, Victoria Island, Lagos, Nigeria

Telephone: 08141304026-9
www.axamansard.com

AXA GLOBAL HEALTH PLAN

Individual application form
Checklist – please ensure:
• You have read, signed and dated the declaration in Section 9 and 10.
• The information you have given in Section 1-8, 10 are correct and complete.
• Please complete this form using BLACK INK and write in BLOCK CAPITALS throughout and tick (√) in the relevant
boxes.
• The main applicant (Policyholder) must be at least 18 years old.
• For inclusion of new applicants under 18, this form must be signed by their parent/guardian.
Please note:
• In order to avoid unnecessary delay in the processing of your application, it is important that you provide all
information required in this application and a complete answer for each question including dates, where
applicable. If you do not answer the questions, we shall take that to mean that you have nothing to disclose.
• To include a photocopy of the passport or identification cards for all applicants applying for the plan/covers.
• Additional information may be required after review of application
• Cover will not commence until underwriting process is completed
1. YOUR PERSONAL DETAILS (Main Applicant)

1.1 Full Name and Title Mr. Mrs. Ms. Miss. Other – Please state

FIRSTNAME AND MIDDLE NAME IN FULL LAST NAME

1.2 Marital status 1.3 Gender MALE FEMALE

1.4 Correspondence address

This is where we will send the policy documents. Please give full address details, including postal code and country where applicable.

ADDRESS

POSTCODE COUNTRY

1.5 Telephone no. (include country and area code)

This is the number that is most appropriate to contact you on, Monday to Friday between 9am and 5pm (GMT)
Daytime Evening

1.6 Email address 1.7 Fax no. (include country and area code)

1.7 Occupation/ 1.8 Industry

job duties

1.10 Weight (kg) Height (m) 1.11 Date of birth

Issued by AXA Mansard Health Limited – Reinsured by AXA PPP healthcare Limited 1/7
 1.8 Principal country of residence 1.12 Nationality

Principal country of residence refers to the country you live or intend to live for 1.13 Customer number
most of the year being 185 days or more. If your principal country of residence is If already a member of AXA Mansard Global Health or International
the United States of America or Canada, this policy will terminate at the end of Health Plan, AXA PPP healthcare or any AXA Global Healthcare
the first year. American and Canadian citizens whose principal country of Plans (shown as membership number)
residence is either the USA or Canada are not eligible to apply for an AXA Global
Health Plan. Customer number:

2. ADDITIONAL FAMILY MEMBERS (spouse and child(ren) to be included in the plan)

2.1 TITLE FIRST NAME LAST NAME GENDER (M/F)

DATE OF BIRTH RELATIONSHIP TO POLICYHOLDER NATIONALITY

WEIGHT (KG) HEIGHT (M) PRINCIPLE COUNTRY OF RESIDENCE

OCCUPATION/ JOB DUTIES INDUSTRY

2.2 TITLE FIRST NAME LAST NAME GENDER (M/F)

DATE OF BIRTH RELATIONSHIP TO POLICYHOLDER NATIONALITY

WEIGHT (KG) HEIGHT (M) PRINCIPLE COUNTRY OF RESIDENCE

OCCUPATION/ JOB DUTIES INDUSTRY

2.3 TITLE FIRST NAME LAST NAME GENDER (M/F)

DATE OF BIRTH RELATIONSHIP TO POLICYHOLDER NATIONALITY

WEIGHT (KG) HEIGHT (M) PRINCIPLE COUNTRY OF RESIDENCE

OCCUPATION/ JOB DUTIES INDUSTRY

2.4 TITLE FIRST NAME LAST NAME GENDER (M/F)

DATE OF BIRTH RELATIONSHIP TO POLICYHOLDER NATIONALITY

WEIGHT (KG) HEIGHT (M) PRINCIPLE COUNTRY OF RESIDENCE

OCCUPATION/ JOB DUTIES INDUSTRY

2.5 TITLE FIRST NAME LAST NAME GENDER (M/F)

DATE OF BIRTH RELATIONSHIP TO POLICYHOLDER NATIONALITY

WEIGHT (KG) HEIGHT (M) PRINCIPLE COUNTRY OF RESIDENCE

OCCUPATION/ JOB DUTIES INDUSTRY

Issued by AXA Mansard Health Limited – Reinsured by AXA PPP healthcare Limited 2/7
3. MEDICAL PRACTITIONER(S) MOST FREQUENTLY CONSULTED IN THE LAST 5 YEARS

Name of Medical Specialization

Name and address of (e.g. General Practitioner or Specialist in
Practitioner(s) clinic or hospital
(First and Last Name) which branch of medicine or surgery)

Main Applicant

Spouse

Child 1

Child 2

Child 3

Child 4

*Please provide details and continue on a separate sheet if necessary.

4. YOUR CURRENCY FOR YOUR POLICY

Your premiums are payable in US Dollars (USD).

US DOLLAR If you wish to pay your premium in Naira (NGN), please contact us via corporate@axamansard.com to assist you with this request.
For any claim’s reimbursement, this will be paid in the same currency in which you pay your premiums.
5. TYPE OF COVER REQUIRED (eligibility as specified/designated by your company) 6. PREFERRED START DATE*

CHOOSE THE LEVEL OF COVER YOU REQUIRE PRIME CLASSIC STANDARD Date

*Please note that the underwriting process will take about 14 days.
7. PAYING YOUR PREMIUM (Premium is payable on an annual basis.)
*Please make your cheque payable to
I WOULD LIKE TO PAY MY PREMIUM BY Direct Debit Credit Card Cheque* AXA Mansard Health Limited (annual payment)

7.1 Credit card authorization

Credit card authorization form:
To: AXA Mansard Health Limited, I authorize you, until further notice in writing, to charge to my Mastercard / Visa account unspecified amounts in
respect of my AXA Mansard Health Limited, premiums as and when they become due, until this instruction is countermanded by my giving notice in
writing to AXA Mansard Health Limited. You will be given at least 7 days' notice of any premium increase.

CREDIT CARD NUMBER CARD TYPE Mastercard Visa

DATE REFERENCE

FIRST NAME (as on credit card) LAST NAME (as on credit card)

ADDRESS OF CARDHOLDER SIGNATURE:

COUNTRY POSTCODE PHONE# DATE

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7.2 Instruction to your Bank or Building Society to pay by Direct Debit

Please fill in the whole form (including the official use box if appropriate) and send to:
AXA Mansard Health Limited, 84b, Ozumba Mbadiwe Street, Victoria Island, Lagos, Nigeria
NAME(S) OF ACCOUNT HOLDER(S):

BANK/BUILDING SOCIETY ACCOUNT NUMBER: BRANCH SORT CODE:

NAME AND FULL POSTAL ADDRESS OF YOUR BANK OR BUILDING SOCIETY

To The Manager: Bank/Building Society:

Address: Postal code:

__________________________________________________________________________________________________________________________________________________

REFERENCE: (AXA MEMBERSHIP No.)

Instruction to your Bank or Building Society

Please pay AXA Mansard Health Limited Direct Debits from the account detailed in this instruction, subject to the safeguards assured by the Direct Debit
Guarantee. I, the undersigned understand that this instruction may remain with AXA Mansard Health Limited and, if so, details will be passed
electronically to my Bank/Building Society. I understand and agree that AXA Mansard Health Limited maintains the right to charge the value and rate of
the amounts deducted from this account.

SIGNATURE:

DATE

Banks and building societies may not accept Direct Debit Instructions for some types of account.

FOR AXA MANSARD HEALTH OFFICIAL USE ONLY. (This is not part of the instruction to your bank or building society.)
Please complete this box if you are paying on behalf of the lead member.
NAME OF ACCOUNT HOLDER: ADDRESS OF ACCOUNT HOLDER:

Please keep a copy of this guarantee ( to be retained by the payer)

The Direct Debit Guarantee

• This Guarantee is offered by all banks and building societies that accept instructions to pay Direct Debits.
• If there are any changes to the amount, date or frequency of your Direct Debit, AXA Mansard Health Limited will
notify you 7 working days in advance of your account being debited or as otherwise agreed. If you request AXA
Mansard Health Limited to collect payment, confirmation of the amount and date will be given to you at the time of the request.
• If an error is made in the payment of your Direct Debit, by AXA Mansard Health Limited or your bank or banking society, you are entitled to
a full and immediate refund of the amount paid from your bank or building society. If you receive a refund you are not entitled to, you must
pay it back when AXA Mansard Health Limited asks you to.
• You can cancel a Direct Debit at any time by simply contacting your bank or building society. Written confirmation may be required. Please
also notify us.

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8. CONFIDENTIAL MEDICAL HISTORY
Please answer all the questions in full and to the best of your knowledge and belief.
If you have any doubts whether something may influence how we deal with your application (we call these material facts), you should include it as
your policy may be invalid entirely if you fail to disclose any material facts. If for any reason you do not answer a question, we shall take that as
meaning you have nothing to disclose.
Please note, once you have joined we do not pay for treatment of any medical condition (or treatment of any medical condition arising from or
associated with such a medical condition) which you already had when you joined and which you should have told us about but did not tell us at all or
did not tell us everything unless you have declared it and we have not excluded it. This includes any such medical condition(s) or symptoms, whether
being treated and any previous medical condition(s) which recurs or which you should reasonably have known about even if you had not consulted a
doctor.
Please give details of all those individuals who answer 'Yes' to any questions. By treatment we mean surgical or medical services (including medication
prescribed by a specialist) that are needed to diagnose, relieve or cure a disease, illness or injury.
Please note: You are advised to keep a record of all information supplied in connection with this application, including any letters you send to us in
connection with it. If you would like a copy of this application form please let us know within three months.

Part A.
You must declare your medical history even if you have been insured with us or anyone else before.
You Spouse Child 1 Child 2 Child 3 Child 4

8.1 Have you or any members of your family (if included in this Yes Yes Yes Yes Yes Yes
application) consulted with a medical practitioner, been
admitted to hospital or nursing home, or suffered from an
intermittent or recurring illness and/or pre-existing conditions No No No No No No
during the last five years?

8.2 Have you or any members of your family (if included in this Yes Yes Yes Yes Yes Yes
application) consulted with a medical practitioner or a health
professional or an alternative practitioner, or taken any
medication in the past 2 years? No No No No No No

8.3 Have you or any members of your family (if included in this Yes Yes Yes Yes Yes Yes
application) had any medical condition, disability or health
problem, not mentioned above, whether or not a doctor has
been consulted, for example, gynecological or menstrual No No No No No No
problems, complications of pregnancy, signs or symptoms of
varicose veins, back trouble, joint disorders, joint replacements,
foot problems (e.g. bunions), indigestion or bowel problems,
abdominal pain, skin problems, allergies, anxiety, depression or
other psychiatric problems, trouble with heart, limbs, ears, eyes,
urination etc., and is there any other information which you
should, in good faith, disclose?

8.4 Is there any known or foreseeable need to consult any doctor or Yes Yes Yes Yes Yes Yes
other health professional?
No No No No No No

8.5 Do you or anyone else covered on your policy suffer from AIDS or Yes Yes Yes Yes Yes Yes
HIV or are currently awaiting treatment, investigations, check
ups or the results of investigations for AIDS or HIV?
No No No No No No

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Part B.
Additional information (please continue on a separate sheet if necessary. Tick (√) this box if attached
8.6 If you have answered yes to any of the questions in part A please give full details here or anything else you should
disclose to us in good faith.
QUESTION NO. NAME OF APPLICANT NATURE OF ILLNESS AND FINAL DIAGNOSIS

DURATION PERIOD OF ILLNESS

PRESENT STATE OF HEALTH IN THIS RESPECT

QUESTION NO. NAME OF APPLICANT NATURE OF ILLNESS AND FINAL DIAGNOSIS

DURATION PERIOD OF ILLNESS

PRESENT STATE OF HEALTH IN THIS RESPECT

QUESTION NO. NAME OF APPLICANT NATURE OF ILLNESS AND FINAL DIAGNOSIS

DURATION PERIOD OF ILLNESS

PRESENT STATE OF HEALTH IN THIS RESPECT

QUESTION NO. NAME OF APPLICANT NATURE OF ILLNESS AND FINAL DIAGNOSIS

DURATION PERIOD OF ILLNESS

PRESENT STATE OF HEALTH IN THIS RESPECT

QUESTION NO. NAME OF APPLICANT NATURE OF ILLNESS AND FINAL DIAGNOSIS

DURATION PERIOD OF ILLNESS

PRESENT STATE OF HEALTH IN THIS RESPECT

QUESTION NO. NAME OF APPLICANT NATURE OF ILLNESS AND FINAL DIAGNOSIS

DURATION PERIOD OF ILLNESS

PRESENT STATE OF HEALTH IN THIS RESPECT

QUESTION NO. NAME OF APPLICANT NATURE OF ILLNESS AND FINAL DIAGNOSIS

DURATION PERIOD OF ILLNESS

PRESENT STATE OF HEALTH IN THIS RESPECT

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9. ADDITIONAL INFORMATION

If you answered "Yes" under Section 8, the following space is for any additional medical history declaration. Please specify the question, applicant(s)
name(s) and details of their respective medical history.

10. PRIVACY NOTICE

Before you sign and return this form, please show the following statement to anyone over the age of 16 that you wish to cover on this plan or inform
them of its contents.

By signing and returning this form you indicate that you have authority to give consent on behalf of any family members covered by your policy and,
on your own and their behalf, you consent to the use of personal information as set out in this Privacy Notice.
AXA Mansard Health Limited is committed to protecting your privacy in accordance with relevant Privacy laws and regulations. This notice will explain
how we (in this notice "we", "our" and "us") includes AXA Mansard Health Limited, reinsurer AXA PPP healthcare Limited ("AXA PPP") and AXA Global
Healthcare collect, use and protect your personal data. We will also explain what rights you have with regards to your personal data and how you can
exercise those rights.
We want to reassure you we never sell personal member information to third parties. We will only use your information in ways we are allowed to by
law, which includes only collecting as much information as we need. We will get your consent to process information such as your medical information
when it's necessary to do so.
We collect information about you and the family members who are covered by your policy from you, those family members, your healthcare providers,
your employer (if you are on a company scheme), your intermediary or insurance broker if you have one and third party suppliers of information, such
as credit reference agencies. We accept individuals under the age of 16 as a child, and would collect and record their data only upon consent from the
child's parent / guardian.
We process your information mainly for managing your membership and claims, including investigating fraud. We also have a legal obligation to do
things such as report suspected crime to law enforcement agencies. We also do some processing because it helps us run our business, such as research,
finding out more about you, statistical analysis for example to help us decide on premiums and marketing.
We may disclose your information to other people or organizations. For example, we will do this to:
▪ manage your claims, e.g. to deal with your doctors.
▪ manage your policy with your intermediary or insurance broker
▪ help us prevent and detect crime and medical malpractice by talking to other insurers and relevant agencies; and
▪ allow other AXA companies to contact you if you have agreed.

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 In order to manage your policy, we may access your information from countries anywhere in the world. For these purposes, we may also perform
international transfer of your data. Before doing so we will ensure that your data is protected and disclosed only to authorised individuals solely
servicing your policy or claim.
Where our using your information relies on your consent you can withdraw your consent, but if you do so we may not be able to process your claims or
manage your plan properly. We will inform you if a data breach occurs and your personal information are disclosed to unauthorised parties. The
notification will be provided within 72 hours of the confirmation of the incident. In some cases you have the right to ask us to stop processing your
information or tell us that you don't want to receive certain information from us, such as marketing communications. You can also ask us for a copy of
information we hold about you and ask us to correct information that is wrong.
If you want to ask to exercise any of your rights you can call us or write to us.

11. DECLARATION

I declare that:
• to the best of my knowledge and belief the statements on this application form are full, true and correct,
• that I shall read the policy handbook when received and that I agree to be bound by it unless I shall cancel the enrolment within 14 days of
acceptance of my application.
I understand that if there are changes in the information I have given before the start date of my policy, I must inform you in writing immediately. I agree
that the acceptance of my application shall be on the basis of these statements.
I understand that once the policy has started, you will not pay for treatment of any medical condition (or related medical condition) which I or any of
the applicant(s) already had when I/ we joined unless fully disclosed on this application and accepted by you. This includes any such medical
condition(s) or symptoms, whether or not being treated and any previous medical condition(s) which recurs, or which I/ we should reasonably have
known about even if I/ we had not consulted a doctor.
I understand that as the legal holder of this insurance policy, you will send all correspondence about this application, including claims correspondence,
to me unless I write to tell you otherwise. I also understand that you will issue policy documents, written communications and membership details in
English unless you and I have specifically agreed, in writing, to communicate in a different language.
I understand that some countries require residents, whether expatriates or otherwise, to take out health cover through a local provider or to hold cover
which meets certain compulsory requirements and that the cover offered by you may not meet these country specific requirements and therefore
additional cover may be necessary. I further understand that in some situations there may be consequences in the form of tax penalties or otherwise
where a resident does not hold the required local cover in addition to their international medical insurance policy. If I have any concerns about any
additional cover requirements in my principal country of residence, I understand that it will be my responsibility to check with the local authorities to
determine whether there are any further healthcare requirements with which I am expected to comply.
By signing and returning this form I confirm that I have the authority to enter this policy on behalf of any family members.

MAIN APPLICANT’S SIGNATURE

(This form must be hand signed. We do not accept electronic signatures.)
SIGNATURE If the Policyholder is under 18, this form must be signed by their parent/legal guardian.

DATE

SIGNATORY'S FULL NAME

After completing this application form and signing the declaration, please return to:

AXA Mansard Health Limited (RC 487419)

84b, Ozumba Mbadiwe Street, Victoria Island, Lagos, Nigeria

Telephone:08141304026-9
www.axamansard.com

Issued by AXA Mansard Health Limited – Reinsured by AXA PPP healthcare Limited

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