AKD Insurance DCare Quotation

About You

Dependants

Quote

Apply & Buy

About You

Who is this cover for?

Just yourself

Yourself and additional people

Medical Declaration

Title:*

Name:*

Surname:*

ID/Passport Number:*

TIC:*

Nationality:*

Gender:*

Occupation:*

Height (cm):*

Weight (kg):*

Primary Telephone:

Mobile Telephone:*

Fax:

E-Mail:

*All correspondence will be done on the above e-mail address

Please select the box to confirm that above e-mail address is correct.

Residential Address

Street Address:*

Town/City:*

District:

Post Code:*

Country:*

Mail Forwarding Address

Same as residential address

Add new mail forwarding address

Mail Forwarding Address

Street Address:

Town/City:

District:

Post Code:

Country:

Medical Declaration: If the answer to any question in this Section is “Yes” for you or any other applicant, that person may not be eligible for this insurance or, if they are eligible for this insurance, additional terms and conditions (to those contained in the Policy Wording) may be applied. There may be circumstances where a “Yes” answer results in the insurer requiring additional information (to that provided in this Application Form) in order to make a decision. Please answer Questions 1-5 for all applicants.

Are you or any other applicant presently hospitalised, or scheduled for, or (based on a medically confirmed opinion) in need of, hospitalisation or surgery?

Yes

Have you or any other applicant at anytime ever tested positive for, been diagnosed with, or been treated for Acquired Immune Deficiency Syndrome (AIDS), AIDS Related Complex (ARC), Lymphadenopathy Syndrome, Human Immunodeficiency Virus (HIV) or any other Immunes System Disorder?

Yes

Have you or any other applicant at any time ever had, been recommended to have, or are you currently on a waiting list for any organ transplant (other than corneal)?

Yes

Have you or any other applicant at any time ever been diagnosed with or treated for any type of cancer or pre-cancerous condition? If Yes, please complete Further Medical Information. Cancer tumour, cyst, polyp, melanoma, Kaposi’s sarcoma, cell disorder, shingles, lump, calcification or growth of any kind?

Yes

Are you or any other applicant currently pregnant - if yes please provide due date

Yes

Applicants selecting Medical Cover on a Moratorium Application (under Section 2.6) please proceed to Section 6. Applicants selecting Medical Cover on a Continued Personal Medical Exclusions (CPME) Application (under Section 2.6), please complete questions 6 - 22 below and Section 5. All other applicants please complete questions 6-22 below.

During the past 2 years, have you or any other applicant experienced manifestation or symptoms of, suffered from, sought or received any consultations, examination, testing been treated for, orreceived treatment (including medications) for, or been diagnosed with any mental health, physical or nervous condition of whatsoever nature? If yes, please complete Further Medical Information.

Yes

Have you or any other applicant experienced manifestation or symptoms of, suffered from, sought or received any consultations, examination, testing or been treated for, or received treatment for, or been diagnosed with any disease, condition, illness, injury, medical problem, disorder, sickness or other problem directly or indirectly arising from, involving or relating to the following:

Heart, cardiac, cardiovascular and/or circulatory, including but not limited to: congestive heart failure, heart attack, angina, chest pain, arteriosclerosis, atherosclerosis, elevated blood pressure, hypertension, swelling of feet/ankles, thrombo- sis, phlebitis, rheumatic fever, or heart murmur? If yes, please complete Further Medical Information:

Yes

Blood, Blood vessels, spleen, arteries, veins or disorders of the blood, including but not limited to: anaemia, haemophilia, leukemia, hepatitis, lymph glands or high cholesterol

Yes

Diabetes, hyperglycemia or hypoglycaemia? If yes to diabetes, please complete Further Medical Information:

Yes

Asthma or allergies? If yes, Further Medical Information is needed, please specify which one and complete the following:

Yes

Liver, Pancreas, Gall Bladder or endocrine disorders including but not limited to: Pituitary, thyroid or metabolic disorders or obesity?

Yes

Kidney, urinary tract functions, kidney or bladder stones or infections?

Yes

Respiratory system including but not limited to: Tuberculosis, lung disorders, emphysema, chronic cough, bronchitis, bronchial asthma, pleurisy or pneumonia?

Yes

Mental and nervous system disorders including but not limited to: Psychosis, mental or behavioural disorders, chemical or drug abuse or dependency, alcoholism, psychiatric counselling and/or support groups, depression, anxiety, chronic fatigue, or eating or sleeping disorders?

Yes

Neurological disorders, including but not limited to: Multiple sclerosis (MS), muscular dystrophy, Lou Gehrig’s disease (ALS), Parkinson’s disease, paralysis, epilepsy, convulsions, seizures, migraines, chronic headaches, stroke, or transient cerebral ischemic attacks?

Yes

Muscular, skeletal, spine, bone, or joint, including but not limited to: Scoliosis, disc disease or disorder, vertebrae de-generation or any other back or neck condition, rheumatism, arthritis, gout, tendonitis, osteoporosis or inflammation?

Yes

For Female applicants, miscarriage, complicated pregnancy or delivery, infertility consultation/advice/diagnosis or treatment, vaginal bleeding, fibroids, nodules or breast cysts, fallopian tubes, ovaries or uterus?

Yes

For Male applicant, reproductive systems including but not limited to: Prostate or elevated PSA or infertility consultation/advice/diagnosis or treatment?

Yes

Congenital, genetic or hereditary or other birth condition or defect including but not limited to: Developmental disability, Down Syndrome, or other chromosome disorder, physical disorder, deformity or defect?

Yes

Digestive system, stomach, or intestines, including but not limited to: Esophageal regurgitation, gastritis, ulcers, colon, or rectum disorders?

Yes

Eyes, ears, nose, mouth, throat or jaw, including but not limited to: Cataracts, glaucoma, nasal septum deviation, chronic sinusitis, or temporomandibular joint?

Yes

Any other disease, condition, illness, injury, medical problem, disorder, sickness or other problem of any kind not listed?

Yes

Switch Health Declaration: This Section must be completed if you or any other applicant is currently insured under another medical expenses policy and wish to become insured under the DCare International Medical Insurance Policy instead.

Optional Section

Do you consent to the processing of your personal data by the insurer for the purposes of underwriting, administering and operating your insurance policy? (please read our privacy policy AKD Insurance Privacy policy)

Yes

If any of the above Medical Questions is YES, Please upload relevant Medical Reports or Documents.

Payment Method

Monthly payments can only be processed with Direct Debit. Paying by Bank Transfer, please do not send your bank details as you will be provided with a payment link once your policy has incepted.

SEPA DDM (Direct Debit)

Bank Transfer

Declaration

I hereby declare that all the above information provided is true and complete and that I have not withheld or misrepresented any information or fact, nor have I stated anything inaccurate. I agree that this Application Form and Declaration are binding on me and shall form the basis of the Policy Contract between myself and the insurer and that the Declaration shall be incorporated in the Policy Contract to be issued. I also declare that I have been informed and hereby accept that the insurer’s liability commences upon acceptance of this Application Form and issuance of the Policy Contract.