ISHCP - Health insurance - print applicationform

INTERNATIONAL SCIENCE

HEALTHCARE PLAN

APLLICATIONFORM

* = compulsorily

Insured Persons * (Please complete the following details for all persons to be insured)

	Family Name	First Name	Date of Birth	Gender
Scholarship holder*				male female
Spouse				male female
Child				male female
Child				male female
Child				male female

Optional Maternity Care benefit * yesno

Policy Period *

from

until

Home Country *

Postal Address of your Institute in Germany *

Sponsoring Organization * (please send a copy of your scholarship confirmation as well)

Current Postal Address *

E-Mail for Cover Confirmation *

Miscellaneos (e.g.:additional children, varying insurance periods, etc.)

Declaration: I acknowledge that all pre-existing conditions as defined in the exclusions are not covered. I confirm that the details made in this application describe the basis of the contract between the policyholder and the insurer. The General Terms and Conditions will be sent to me together with the Policy Documentation. I accept these General Terms and Conditions to be part of contract of insurance issued as a result of this Application.

I authorise the release of any medical information to the Insurer or to the Claims Service acting on behalf of the Insurer as is required to settle all eligible benefits to me, my spouse or children for this claim. A copy of this authorisation shall be considered as effective and valid as the original.

Signature of Scholarshipholder		Date: