Cigna Close CareSM application form

Cigna Close Care

application form

Hello! We’re glad you would like to join us

If Yes, how many per day? Less than 20 per day 20 or more per day

Have you smoked, or used tobacco or nicotine replacement products in the last 12 months? Yes No

Height:

Feet Inches Centimetres Weight: Stones Pounds Kilogrammes

Email address

Daytime telephone number

(Country code – Number)

Mobile telephone number

(Country code – Number)

Fax (Country

code – Number)

Country

Zip/Postal Code

Correspondence address (If applicant is a US National, address must be outside the United States)

Address line 1

Address line 2

Address line 3

Country

Zip/Postal Code

Address in location country (if known)

Address line 1

Address line 2

Address line 3

Location (The country in which you live/will live for the majority of your time for the period of cover)

Nationality (What is the nationality on your passport that you will use to register this policy?)

Address

City State Zip/Postal Code

Please provide your US address below if you are currently located in one of the following states: AZ, CA, CT, DC, FL, IL, IN, KS, LA, MI, NH, OH, SC, TN, TX, UT, VA.

If not located in one of the above states, please proceed to Nationality question

If yes, please identify state: If no, please proceed to Nationality question

Are you currently in the US? Yes No

Are you a Politically Exposed Person?

(see explanatory notes above)

Yes No Occupation

SECTION A

APPLICATION DETAILS

Please complete this section for all persons to be covered under the policy, including the main policyholder and any

dependents.

POLICYHOLDER

You must notify us of any change of contact details so we can ensure that correspondence reaches you.

Title First Name Other Initials Surname

Gender (please tick) Male Female Date of birth (DD/MM/YYYY)

Please complete this application form and return it to us. See our contact information at the end of this form.

To satisfy certain regulatory requirements, you must state in Section A below whether you or any other person

receiving cover under the policy is a Politically Exposed Person. For clarity, you may be dened as a Politically Exposed

Person if you, your family member, or a close associate holds a prominent public function including but not limited to a

politician, senior government employee, judicial or military ocial, ambassador or senior executive of a state owned or

international corporation.This requirement is only applicable if your policy is arranged through our Dubai International

Finance Centre oce.

DEPENDENT 1

Title First Name Other Initials Surname

Relationship to policyholder Gender (please tick) Male Female

Are you a Politically Exposed Person?

(see explanatory notes above) Yes No

Date of birth (DD/MM/YYYY) Occupation

Nationality

(What is the nationality on your passport that you will use to register this policy?)

Location (The country in which you live/will live for the majority of your time for the period of cover)

Email Address

If Yes, how many per day? Less than 20 per day 20 or more per day

Have you smoked, or used tobacco or nicotine replacement products in the last 12 months? Yes No

Height:

Feet Inches Centimetres Weight: Stones Pounds Kilogrammes

DEPENDENT 2

Title First Name Other Initials Surname

Relationship to policyholder Gender (please tick) Male Female

Are you a Politically Exposed Person?

(see explanatory notes above) Yes No

Date of birth (DD/MM/YYYY) Occupation

Nationality

(What is the nationality on your passport that you will use to register this policy?)

Location (The country in which you live/will live for the majority of your time for the period of cover)

Email Address

If Yes, how many per day? Less than 20 per day 20 or more per day

Have you smoked, or used tobacco or nicotine replacement products in the last 12 months? Yes No

Height:

Feet Inches Centimetres Weight: Stones Pounds Kilogrammes

DEPENDENT 3

Title First Name Other Initials Surname

Relationship to policyholder Gender (please tick) Male Female

Are you a Politically Exposed Person?

(see explanatory notes above) Yes No

Date of birth (DD/MM/YYYY) Occupation

Nationality

(What is the nationality on your passport that you will use to register this policy?)

Location (The country in which you live/will live for the majority of your time for the period of cover)

Email Address

If Yes, how many per day? Less than 20 per day 20 or more per day

Have you smoked, or used tobacco or nicotine replacement products in the last 12 months? Yes No

Height:

Feet Inches Centimetres Weight: Stones Pounds Kilogrammes

DEPENDENT 4

Title First Name Other Initials Surname

Relationship to policyholder Gender (please tick) Male Female

Are you a Politically Exposed Person?

(see explanatory notes above) Yes No

Date of birth (DD/MM/YYYY) Occupation

Nationality

(What is the nationality on your passport that you will use to register this policy?)

Location (The country in which you live/will live for the majority of your time for the period of cover)

Email Address

If Yes, how many per day? Less than 20 per day 20 or more per day

Have you smoked, or used tobacco or nicotine replacement products in the last 12 months? Yes No

Height:

Feet Inches Centimetres Weight: Stones Pounds Kilogrammes

SECTION B

APPLICANT DETAILS

When do you want your cover to begin? (DD/MM/YYYY)

CORE COVER

Choose your deductible

$0 $375 $750 $1,500 $3,000 $7,500 $10,000

€0 €275 €550 €1,100 €2,200 €5,500 €7,400

£0 £250 £500 £1,000 £2,000 £5,000 £6,650

Then, select your cost share percentage

No cost share 10% 20% 30%

Choose your out of pocket maximum

(This is the maximum amount of cost share under the Core Cover you must pay in the event of a claim or claims per period of cover).

$2,000 $5,000

€1,480 €3,700

£1,330 £3,325

OPTIONAL BENEFITS

Do you wish to upgrade your plan with any of the following options

Outpatient and Wellness Care Deductible

Yes No $0 $150 $500 $1,000 $1,500

€0 €110 €370 €700 €1,100

£0 £100 £335 £600 £1,000

Cost share after deductible (a $3,000 / €2,200 / £2,000 out of pocket maximum is

applied to cost shares on the Outpatient and Wellness Care option)

No cost share 10% 20% 30%

Dental Care and Treatment

Yes No

USA coverage

(applicable to US nationals only)

Yes No

If you are a US national and do not select to purchase USA coverage, you will not be covered for temporary trips home.

Please note that the Outpatient and Wellness Care, Dental Care and Treatment and USA coverage options can only be purchased with your Core cover.

Please note that each plan chosen will apply to all dependents.

Your plan selection can only be amended at policy renewal. Should you wish to increase your level of cover at renewal, full medical underwriting and waiting periods may apply and

an additional premium amount will be payable.

SECTION C

CONFIDENTIAL HEALTH QUESTIONNAIRE

Please tell us about past and present medical history for yourself and each person named in Section A. If you tick Yes to a question, please provide

full details in Section D.

Once your application has been submitted we may need to contact you for further information before we can nalise your cover.

Careless or deliberate misrepresentation could result in Cigna rejecting claims, and/or cancelling cover. If you need help completing your application,

please contact us.

If you are unsure about the answer to any question you should make the enquiries necessary to allow you to provide an accurate answer.

Please note, if you have disclosed any medical information on a previous call or correspondence, you will be required to disclose this information again

when answering the following medical questionnaire.

YOUR PLAN

Has any applicant received treatment, tests or investigations

for, or been diagnosed with, or had any symptoms of:

POLICYHOLDER DEPENDENT 1 DEPENDENT 2 DEPENDENT 3 DEPENDENT 4

Diabetes and other endocrine (glandular) disorders e.g.

any thyroid disorder, weight problems, gout, pituitary or

adrenal gland conditions.

Yes No Yes No Yes No Yes No Yes No

Heart or circulatory disorders e.g. chest pain, heart attack,

high blood pressure, vascular disease, coronary artery

disease, angina, irregular heartbeat, aneurysm or heart

murmur.

Yes No Yes No Yes No Yes No Yes No

Cancer, tumours or growths including polyps, cysts or

breast lumps.

Yes No Yes No Yes No Yes No Yes No

Muscle or skeletal problems e.g. back pain, whiplash,

arthritis, joint pain or problems, gout, fractures, cartilage,

tendon or ligament problems.

Yes No Yes No Yes No Yes No Yes No

Asthma, allergies, breathing or respiratory disorders e.g.

chest infections, pneumonia, bronchitis, shortness of breath,

rhinitis, TB, emphysema or chronic obstructive pulmonary

disease.

Yes No Yes No Yes No Yes No Yes No

Gall bladder, stomach, intestinal, gastric or liver problems

e.g. irritable bowel disease, colitis, Crohn’s disease, gastric

or peptic ulcers, reux, indigestion, heartburn, gall stones,

hernia, haemorrhoids or hepatitis.

Yes No Yes No Yes No Yes No Yes No

Brain or neurological disorders e.g. multiple sclerosis,

epilepsy or seizures, stroke, migraines, recurring or severe

headaches, meningitis, shingles or nerve pain.

Yes No Yes No Yes No Yes No Yes No

Skin problems e.g. eczema, acne, moles, rashes, allergic

reactions, cysts, dermatitis or psoriasis.

Yes No Yes No Yes No Yes No Yes No

Blood, infective or immune disorders e.g. high cholesterol,

anaemia, malaria, HIV or systemic lupus erythematosus.

Yes No Yes No Yes No Yes No Yes No

Urinary or reproductive disorders e.g. urinary tract

infections, kidney problems, broids, painful, irregular

or heavy periods, fertility problems, polycystic ovarian

syndrome, endometriosis, testicular or prostate problems.

Yes No Yes No Yes No Yes No Yes No

Anxiety, depression, psychiatric or mental health issues

including eating disorders, post-traumatic stress disorder,

alcohol or drug issues.

Yes No Yes No Yes No Yes No Yes No

Ear, nose, throat, eye or dental problems e.g. ear

infections, sinus problems, tonsils and adenoids, cataracts,

glaucoma, wisdom teeth problems.

Yes No Yes No Yes No Yes No Yes No

Please also answer the following questions:

Does anyone have any illness, condition or symptom not

already mentioned?

Please include details of any known or suspected issues

whether or not medical advice has been sought or a

diagnosis reached.

Yes No Yes No Yes No Yes No Yes No

Does anyone take any medication, receive any treatment

of any kind or expect to have a review or follow up for any

current or past medical problem not already mentioned?

Yes No Yes No Yes No Yes No Yes No

SECTION D

ADDITIONAL HEALTH INFORMATION

Please tell us more if you have answered ‘Yes’ to any questions in Section C. If you are unsure if any details are relevant, please include them anyway. If

you run out of space, please use a separate sheet.

Section C

Question

Number

The name of the illness or

medical problem. Where

applicable state the area of

the body aected

(e.g. left arm, right foot).

When did the symptoms

occur and when did you last

have symptoms?

What treatment was

provided?

(Include details of medication

and dates of when treatment

started and ended.)

What is the current status

of the illness or medical

problem?

(E.g. ongoing, complete,

recovery, recurrent or likely to

recur.)

POLICYHOLDER DEPENDENT 1 DEPENDENT 2 DEPENDENT 3 DEPENDENT 4

SECTION E

DECLARATION FOR ALL CUSTOMERS

I hereby declare that I have taken reasonable care to answer all questions accurately, honestly and completely. I acknowledge that if I do not answer

all questions accurately and completely as a result of my carelessness or as a result of deliberate or reckless misrepresentation, Cigna may

reject claims, and/or cancel cover as per the terms and conditions of this policy.

The duty to answer our questions accurately, honestly and completely applies in respect of each person who is covered by this policy. Although failure

to full this duty by one covered person may aect coverage or payment of their claims, it will not aect coverage or payment of claims in relation to

any other covered person, unless that person has also made careless, deliberate or reckless misrepresentations in relation to our questions. I warrant

and represent that I have each covered person’s consent to disclose the personal information, including the sensitive personal information (e.g. medical

information) contained in this form to you. I conrm that each covered person is aware of their duty to take reasonable care to answer your questions

accurately, honestly, completely and to the best of their knowledge.

(Please note that if you are declaring the above on another person’s behalf, it is your obligation to keep evidence of the consent you are

providing hereto of your covered family members’ actual declarations and consents.)

I hereby propose to Cigna Healthcare for cover to begin on the cover date or such other agreed date. In the event that it is found that I, or any

covered person, have deliberately or recklessly provided any information which is false or inaccurate, Cigna Healthcare may void the contract of

insurance as it relates to me or the covered person and refuse all claims and need not return any premiums paid in, except for where it would be unfair

for the premiums to be retained. I have carefully read, understood and agree to abide by the Policy Rules and Customer Guide as they form part of my

contract of insurance.

Signature

Date (DD/MM/YYYY)

If you are signing for, or on behalf of, the main policyholder please sign below where you are warranting and representing to us that you have read the

above declaration and have the authority to enter into this application:

Signature/

Date (DD/MM/YYYY)

Select the relationship to main

policyholder

Broker Agent

Other (please specify)

FRAUD NOTICE

Any person who, dishonestly and with intent to make a gain for themselves or cause loss to another, or to expose another to a risk of loss: (1) makes

an application for insurance or makes a claim under a policy containing any information they know to be untrue or misleading; or who (2) in making

an application for insurance or a claim under a policy dishonestly and with intent to make a gain for themselves or cause loss to another, or to

expose another to a risk of loss fails to disclose information which has been asked for, commits fraud. We will investigate any claims or applications for

insurance which we have grounds to believe may be fraudulent. Committing fraud may result in your policy being terminated and any claims you make

under not being paid. We may, for the purposes of the detection and prevention of fraud, share information relating to suspected fraud with other

insurance companies and/or with law enforcement authorities.

SPECIAL OFFERS, PROMOTIONS, PRODUCTS, SERVICES AND RESEARCH

We would like to keep in touch with you to keep you updated about our special oers, promotions, products and services which

we think will interest you. We may also contact you for the purposes of conducting research.

If you would like to receive this information, please tick here

If yes, how would you like us to contact you? Email Telephone

I consent to being contacted by Cigna Healthcare and/or by a third party

that has carefully been selected by Cigna Healthcare for the purposes of

conducting research.

Yes No

HOW WE USE YOUR INFORMATION

We will collect, use, store, and disclose your personal information, including sensitive information (in particular, information relating to your

medical history and any medical treatment you may have or have had), in accordance with relevant data protection legislation. We collect

and will use your personal information, including sensitive information, for the purpose of carrying out our obligations under this plan.

We may share your information, including sensitive information, with other Cigna Healthcare companies, carefully selected third parties including any

broker you appoint to act on your behalf, other providers of services under this plan and authorised healthcare providers, where

necessary to carry out our obligations under this plan. This statement also applies to personal information of any beneciaries detailed on

this application form.

You have the right to request a copy of your personal information held by us, and beneciaries under your policy have the right to

request a copy of personal information we hold about them. We may charge a fee to provide this information.

I acknowledge the collection, use and disclosure of my personal and special category data by Cigna Healthcare for the purposes

required by the contract of insurance I have entered into.

Is the billing address the residence address you have provided for your policy?

Yes No

If no, please provide the full billing address

Credit card authorisation: I authorise Cigna Healthcare to charge my credit/debit card account with my healthcare premium (of which I will be notied

upon acceptance of cover/renewal). This will continue until the instruction is cancelled, and I will provide written notice to Cigna Healthcare according

to my Policy Rules documentation.

Cardholder’s signature

Date (DD/MM/YYYY)

Date of birth of cardholder (DD/MM/YYYY)

Nationality of cardholder

If the cardholder is not the policyholder, please

state the relationship to the policyholder

Other

beneciary

Employer

Company name

Spouse/partner Other

Relationship

Family member

Please conrm that the payment card is that of the policyholder? Yes No

Payment currency US Dollar

Euro Sterling

Payment frequency Monthly Quarterly Annually

Payment method Credit/debit card

Bank wire transfer (Annual payment only)

(We will call you on receipt of your application to provide the relevant details)

Credit/debit card number

Type of card MasterCard Visa Visa Debit Visa Electron American Express

Name as it appears on the card

Start date of the card (MM/YY) Expiry date of the card (MM/YY)

Security code

(This is the 3 digit number on the reverse of most cards. For American Express cards, this is the 4 digit number found on the front of the card

on the right hand side)

SECTION F

Payment details

This page, including your card details, will be securely disposed of once your application has been

processed and the payment details have been securely stored.

Upon completion of the application, please contact our

Broker Sales Team for support.

Telephone: +44 (0) 1475 788 682

Toll free from US: 1-877-539-6296

Email: cgi.sales@cigna.com

For policies arranged through our Dubai International Finance Centre oce, under insurance license Cigna Global Insurance Company Limited, the underwriting agent is

Cigna Insurance Management Services (DIFC) Limited which is regulated by the Dubai Financial Services Authority.

Cigna Healthcare name, logo and other Cigna marks are owned by Cigna Intellectual Property, Inc., licensed for use by The Cigna Group and its operating subsidiaries. All

products and services are provided by or through such operating subsidiaries, and not by The Cigna Group. Such operating subsidiaries include Cigna Global Insurance

Company Limited, Cigna Life Insurance Company of Europe S.A.–N.V., Cigna Europe Insurance Company S.A.-N.V. and Cigna Worldwide General Insurance Company Limited. ©

Close Care

Application Form Broker 09/2023