Application Form for Health Insurance

ExpatCare

実際のご記入はブランクフォームに英語で漏れずにご記入ください
SECTION A

Applicant’s Details

Mr.Mrs.Miss.

苗字Title :Surname :First Name :お名前Sex : ◯ Male ◯ Female

Date of birth :Age :ID/Passport No. :Nationality :Height (cm) :Weight (kg) :Smoker : ◯ No ◯ Yes please speciﬁed …......................

Occupation :職業。または Retired(最終職業)

Residential address of the country where you are to be located :Address :Town / City :Country :Post Code / Zip Code :E-mail Address :Work Contact (Tel.) :Home Contact (Tel.) :SECTION B

Coverage Details

Coverage details (please tick one box only on each line)
Plan :◯ Expat Care 1◯ Expat Care 2◯ Expat Care 3

ご希望の丸にX印お願いします。

Geographical area :◯ Area 1 : Thailand◯ Area 2 : Asia

◯ Area 3 : Worldwide excluding USA

Total Annual Premium (THB) :Page 1 of 4

Application Form Healthcare Insurance - Expat Care

弊社内規定にて、齟齬防止の為下記の告知欄は和訳ご提供できません。
SECTION C

Statement of Health 下記の該当Yes,NoにX印ご記入ください。

Please truthfully provide thorough and precise responses to the following questions to aid us in accurately underwriting your policy.
1.

1.1

1.2

Have you ever experienced symptoms, been diagnosed with, investigated, or received treatment for any of the following diseases or disorders?
Please underline the speciﬁc conditions and provide details, including organ, diagnosis or name of diseases or disorders, symptoms and/ormedical condition, When did the symptoms start? What treatment did you receive and when? (Please include dates and any medication prescribed),
What was the outcome of the treatment? (e.g. ongoing, still under review, complete recovery, recurrent or likely recur), date of last consultationor follow-ups, etc. in section Medical details.
Have you ever had a past history of cancer or pre-cancer (including benign brain tumours),
AIDS, AIDS-related complex, HIV, systemic lupus erythematosus (SLE), Immunodeﬁciency,
Auto-Immune, alcoholism, substance abuse, diabetes type 1, insulin dependence, epilepsy,seizure, heart condition, stroke, chronic obstructive pulmonary disease (COPD), joint disorder,cirrhosis, paralysis, visual loss, blindness, pancreatitis, ascites, psychiatric or mental illness?

◯ Yes◯ NoDo you have any long-term, ongoing or chronic condition for which you have regularappointments or need a review or treatment for?
CHRONIC means an illness or injury which has one or more of the following characteristics:• It has no known recognized cure
• It continues indeﬁnitely• It recurs or is likely to recur• It is permanent• Requires palliative treatment• Requires long-term monitoring, consultations, check-ups, examinations, or tests• Requires rehabilitation or special training to cope with it.

◯ Yes◯ No

Medical Details
Question
Number

該当番号
1.1 またはʼ
1.2

過去の病歴は下記に英文でご記入ください。

Organ

該当ʼの身体ʼ部分
器官名

Diagnosis orname ofdiseases ordisorders
診断名

Symptoms
and/ormedicalcondition
症状

When didthe symptoms
start?
症状ʼ発生の年月日

What treatment
did you receiveand when?
(Please include
dates and any
medicationprescribed)
治療内容

What was theoutcome of
the treatment?
(e.g. ongoingstill under review,complete recovery,recurrent orlikely recur)

Date of lastconsultationor follow-ups

Etc.

最近直近ʼの検査結果ʼ
現状

治療後の経過閣下

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Application Form Healthcare Insurance - Expat CareSECTION C

2.

Statement of HealthHave you ever undergone any specialized medical examinations (such as ultrasound, CT scan,MRI, mammogram, Pap smear, etc.), health and physical check-ups, procedures for investigative
purposes other than those mentioned, or any surgical procedures?
If your answer is yes, please specify the organ and procedure.

◯ Yes

◯ No

◯ Yes

◯ No__________________________________________________________________________________________________________________________
あなたは超音波、CT,MRIなど検査ʼされた事が有りますかʼ？
Yes,の場合は検査対象器官名と検査の内容__________________________________________________________________________________________________________________________For WOMEN ONLY:

女性のみ

Have you had any diseases or disorders of the breast, uterus, ovaries, fallopian tubes, cervix,menstruation, reproductive system, pregnancy, or childbirth, including complications, abortionor miscarriage or have been investigated, and/or treated for infertility?
If your answer is “YES”, please specify diagnosis, treatment, and when?

過去に乳房、子宮ʼなど検査された事が有りますか？
__________________________________________________________________________________________________________________________Yesの場合は結果記載ください。
__________________________________________________________________________________________________________________________*** If the space provided is insufﬁcient, please use a separate sheet. ***Would you like to claim for personal income tax deduction with this health insurance premium?
◯

保険料の所得税控除をご希望ですか？

Yes, and I permit the insurer to send and reveal the information about this insurance premium to Revenue Department.
If the applicant is a non-Thai resident, please enter the taxpayer ID number given by the Revenue Department:_____________________________________________________________________________________________________________________________________________________________________◯No

Data protection :Paciﬁc Cross Health Insurance PCL assures you that all your personal and medical information will be held in strictest conﬁdence andin accordance with applicable legislation. Personal date may be passed or given to third party providers in relation to services which
we provide to you and may be transferred by electronic or other means. You have a right to know what information is held about you,and to amend or delete and date we hold which is inaccurate or out-of-date.

Page 3 of 4

Application Form Healthcare Insurance - Expat Care

Remark :The Applicant hereby requests the Company to provide the insurance policy together with the terms and conditions according to theirpolicy and the Application declares that the above statements are complete and true. The Applicant agrees to have this application
form included in the contract between the Applicant and the Company. Should there be any false statement, or any truth being
concealed, the Applicant agrees to let the Company void this insurance policy.
The Applicant, besides this, assigns the Company to request any kind of information regarding their personal heath treatment or
health condition records from any physician, hospital, clinic or any other organization which has of their health information or records
including the testing results of HIV for the payment of beneﬁts and/or compensation.
The Company has the right to medically examine any Applicant who is claiming a beneﬁt under this policy and has the right to conduct
an autopsy, within the limits of the laws, in case of death, and the expense incurred will be paid by the Company.
If the Applicant does not allow the Company to investigate his/her claim or does not give permission to access his/her medical records
or diagnosis, the Company reserves the right not to pay such claims.
The Applicant allows the Company to collect, use and reveal the truth about the Applicant’s medical records and other information to
the Ofﬁce of Insurance (OIC) in order to regulate the insurance industry.

未成年者の場合は親のサイン(代筆ではない）

申込人サイン
Applicant’s Signature

Guardian’s Signature__________________________________________________________________________________________________________________________________________________________________(_________________________________________________________________________________)(_________________________________________________________________________________)__________________________________________________________

Date / Month / YearWARNING BY OFFICE OF INSURNACE COMMISSION (OIC)The applicant must truthfully answer all questions. Any concealment or misrepresentation of the truth may result in the Insurance
contract becoming void under Clause 865 of the Civil and Commercial Code resulting in the cancellation of the policy.

Pacific Cross Health Insurance PCL
152 Chartered Square Building, 21st Floor, North Sathorn Road, Silom, Bangrak, Bangkok 10500
T: +66 2 401 9189 | F: +66 2 401 9187 | E: contactus@th.pacificcrosshealth.com

PCH-SL-F61_16APR2024

OUR CONTACTINFORMATION

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