Vous êtes sur la page 1sur 10

Please note: these documents are for illustration purposes only, are updated from time to time and

do not form part of any contract with us. To be sure that you are using the most up-to-date and correct version please contact us before making any decision about your cover. We cannot be held responsible for the use of any such electronic material nor bound by the terms shown as material may be damaged by electronic transfer or subjected to unauthorised amendment. Any person or persons found tampering with or misusing this material either in its original form or any other may face prosecution.

Insured by

Reinsured by

AXA INSURANCE HEALTHCARE SERIES


If you are living in the Gulf and are looking for quality health Insurance AXA can provide you with a solution to meet your needs

AXA INSURANCE (Gulf) B.S.C(c)


AXA Insurance (Gulf) B.S.C. (c) Abu Dhabi Head Office, P O Box 245, United Arab Emirates. Telephone:+ 971 2 6775383. Fax + 9712 6771299. Dubai Branch, P O Box 32505, United Arab Emirates. Telephone:+ 971 4 429 4000 Fax: + 971 4 429 4099. Registered in The Insurance Companies Register under Federal Law No.9 of 1984. Certificate Registration No. 68 dated 28th November 2000.

AXA PPP healthcare


AXA healthcare limited. Registered office 5 Old Broad Street, London, EC2N 1AD, United Kingdom. Registered number 3148119 England. Authorised and regulated by the Financial Services Authority. AXA healthcare 2004.

PB33775a/10.08

Depending on where you reside, travel to or wish to receive treatment, there are five options designed to suit your needs:

The AXA Insurance Healthcare Series, developed in a partnership between AXA Gulf and AXA PPP healthcare, has been designed to take into account the needs of people living within the United Arab Emirates, Oman and Qatar.

Some countries do not have state healthcare facilities and even if they do, as a visitor, it is quite likely that youll be entitled to nothing more than basic care.

While abroad, you might find that the standards of healthcare that we take for granted arent always available elsewhere. Local hospitals may be unable to undertake the treatment you need or to arrange transportation to the nearest available healthcare facility in an emergency.

Whether you live within the AGCC or are travelling abroad youll want to feel sure that, should anything happen to you or your family by way of an illness or injury, youll have access to the best possible medical care.

AXA Insurance Healthcare Series for AGCC residents

This top of the range product allows you to choose to have treatment anywhere in the world or at the best known hospitals in the A.G.C.C.. In addition there is no deductible to pay, even for out-patient treatment and you get higher limits on most of the benefits. This is the choice for those who want the benefits of a worldwide plan but are unlikely to need treatment in the USA. This plan is designed for those who want comprehensive cover (in-patient and out-patient) and offers good value for money. These are our most popular plans. They cover you for treatment in North Africa and Middle East as well as the major trading nations of the Indian sub-continent and South-East Asia. Of the two, Regional 1 introduces key elements of the Global Plans such as complementary therapies, health screens, dental cover, vaccination for children and International Emergency Medical Assistance. Under the Regional 2 Plan you benefit from comprehensive cover (in-patient and out-patient) allowing you access to the best medical care available in your country of residence and beyond.

Global 1

Global 2

Regional 1 and Regional 2

Local

This plan is specifically designed for those who want the reassurance of quality healthcare and the security of a substantial overall yearly limit for unexpected high value treatment at a minimal premium. The Local Plan is ideal for those who do not travel extensively outside their country of residence.

Summary table
Benefits

Summary of benefits

International Cover Routine Dental Care (after 9 months membership) Health Screen Cover (after 9 months membership) Regional Cover

Global 1

Global 2

Regional 1

Regional 2

Local

  
After 12 months

  #
After 12 months

#  
After 12 months

#  #
After 24 months

# # #
After 24 months

Pregnancy and Delivery Cover

    

    

    

 #   

 #   

Maintenance of Chronic Conditions Cover (after 9 months membership) Pre-existing Conditions Cover (after 9 months membership) Out-patient direct billing facility in the Gulf Region (after 9 months membership)

Additionally if your child is covered on your policy and is under 18, your plan will cover accommodation expenses for you to stay with them in hospital.

Hospital charges incurred during an in-patient hospital stay are covered giving you peace of mind throughout your hospital treatment. This includes charges for accommodation and cash benefit if you receive free treatment within your area of cover.

In-patient cover

Out-patient network in the AGCC

STAR PLUS

Additionally after nine months membership you can benefit from out-patient direct billing within the AGCC, based on the network shown for your plan. By choosing the AXA International Healthcare Series, you will also have access to the following benefits:

STAR

STAR

STAR

DIAMOND

Additional benefits

Out-patient cover

All of our plans offer full out-patient benefits including cover for general practitioner and specialist consultations, prescribed drugs and dressings and necessary diagnostic tests. Our Global and Regional 1 Plans also include health screening for you and vaccinations for children up to 6 years old.

Available on our Global and Regional 1 Plans, our evacuation and repatriation service is available 24 hours a day, 365 days a year, anywhere in the world. If you cant get the treatment you need locally we will arrange to take you to the nearest place where the treatment is available.

International Emergency Medical Assistance

Administration of policies and claims handled within the UAE

Pre-existing and chronic conditions covered


Our plans provide you with cover for pre-existing and chronic conditions after nine months of consecutive membership. After two years of consecutive cover our plans provide you with an even higher limit. To be sure of these benefits please ensure you declare your existing conditions on the application form.

A team of multinational professionals based in UAE is taking care of your needs in the region. For treatment outside the region we have the global support of AXA PPP healthcare, one of the UKs leading and most experienced healthcare providers.

Global Plans

Your plan options in detail


Benefits Global 1 Global 2 Please note: benefit values are reduced each time you claim only by the net amount (less any deductible, excess or co-insurance) we have actually paid. Area of cover. Worldwide Worldwide excluding USA Yearly maximum up to Dhs/QR 5,000,000 Dhs/QR 2,500,000 OR 500,000 OR 250,000 Outside area of cover Not required for No benefit worldwide cover Level of reimbursement outside the A.G.C.C Reasonable and customary in the country/area of treatment In-patient and daycare treatment Daily accommodation charges Included (single en-suite) Parent accommodation up to Dhs/QR 500, OR 50 per night Cash benefit Dhs/QR 500, OR 50 per night In-patient direct billing Included from enrolment Applicable in-patient direct billing network STAR PLUS & STAR & International International Directory of Hospitals Directory of Hospitals Level of cover 100% of the Reasonable & Customary (R&C) cost in the network shown. Out-patient treatment GP and Specialist consultation charges Included Courses of chiropractic treatment, osteopathy, Dhs/QR 3,000, OR 300 homeopathy and acupuncture up to Courses of physiotherapy Included Per visit deductible (excess) applicable to all Nil Dhs/QR 100 out-patient claims OR 10 Out-patient direct billing Available only after 9 months membership Applicable out-patient direct billing network STAR PLUS STAR Level of cover where your network is 100% of the Reasonable & Customary available (R&C) cost in the network shown. Level of cover where your network is not 100% of the Reasonable & Customary available (R&C) cost in the International Directory of Hospitals. Other benefits Health Screen up to Dhs/QR 2,000, Dhs/QR 1,000, OR 200 OR 100 Available only after 9 months membership Pre-existing conditions up to Years 1 & 2: Dhs/QR 5,000, OR 500 Available only after 9 months membership Subsequent years: Dhs/QR 10,000, OR 1,000 Maintenance of non pre-existing Chronic Years 1 & 2: Dhs/QR 5,000, OR 500 Conditions up to Available only after 9 months membership Subsequent years: Dhs/QR 50,000, OR 5,000 Oral and maxillofacial surgery Included Ambulance transport Included International Emergency Medical Assistance Included Psychiatric treatment up to Dhs/QR 10,000, OR 1,000 Accidental damage to teeth Included Pre and post-natal complications Included Available only after 12 months membership Pregnancy and delivery up to *Dhs/QR 40,000, *Dhs/QR 25,000, OR 4,000 OR 2,500 Vaccination of a child member Dhs/QR 2,000, Dhs/QR 1,000, (up to 6 years of age) up to OR 200 OR 200 Routine Dental Care up to Dhs/QR 4,000, OR 400 No benefit Available only after 9 months membership

After twelve months of consecutive membership Global Plans and Regional 1 Plan include pregnancy and delivery benefit. Regional 2 and Local Plans include pregnancy and delivery benefit after two years of consecutive membership. Unexpected medical complications that occur during the pregnancy are covered under all our plans after 12 months of consecutive membership.

Comprehensive pregnancy and delivery benefit on all our plans

Transferring your policy

Once you have completed a years membership you will be eligible to transfer to an AXA PPP healthcare policy without additional medical underwriting when you leave your principal country of residence. Please remember that we are obliged to meet legal requirements around the world and, as with all providers, cannot absolutely guarantee availability in all countries.

*Only available after 12 months membership. Please see section 2 for terms applying to these benefits.

Regional Plans

*Only available after 12 months membership. **Only available after 24 months membership.

Benefits Regional 1 Regional 2 Please note: benefit values are reduced each time you claim only by the net amount (less any deductible, excess or co-insurance) we have actually paid. Middle East, Middle East, Area of cover. North Africa, North Africa, Indian Sub-Continent Indian Sub-Continent and South-East Asia and South-East Asia Yearly maximum up to Dhs/QR 1,000,000 Dhs/QR 500,000 OR 50,000 OR 100,000 Outside area of cover Up to Dhs/QR 200,000, OR 20,000 (please note there is no cover for treatment in the USA) Level of reimbursement outside the A.G.C.C Reasonable and customary in the country/area of treatment In-patient and daycare treatment Daily accommodation charges Included (single en-suite) Parent accommodation up to Dhs/QR 500, OR 50 per night Dhs/QR 500, OR 50 per night Cash benefit In-patient direct billing Included from enrolment Applicable in-patient direct billing network STAR & International Directory of hospitals Level of cover 100% of the Reasonable & Customary (R&C) cost in the network shown. Out-patient treatment GP and Specialist consultation charges Included Courses of chiropractic treatment, osteopathy, Dhs/QR 3,000, No benefit homeopathy and acupuncture up to OR 300 Courses of physiotherapy Included Per visit deductible (excess) applicable to all Dhs/QR 100, OR 10 out-patient claims Out-patient direct billing Available only after 9 months membership Applicable out-patient direct billing network STAR Level of cover where your network is available 100% of the Reasonable & Customary (R&C) cost in the network shown. Level of cover where your network is not 100% of the Reasonable & Customary available (R&C) cost in the International Directory of Hospitals. Other benefits Health Screen up to Dhs/QR 500, OR 50 No benefit Available only after 9 months membership Pre-existing conditions up to Years 1 & 2: Dhs/QR 2,500, OR 250 Available only after 9 months membership Subsequent years: Dhs/QR 5,000, OR 500 Maintenance of non pre-existing Chronic Years 1 & 2: Dhs/QR 2,500, OR 250 Conditions up to Available only after 9 months membership Subsequent years: Dhs/QR 25,000, OR 2,500 Oral and maxillofacial surgery Included Ambulance transport Included International Emergency Medical Assistance Included No benefit Psychiatric treatment up to Dhs/QR 5,000, OR 500 Accidental damage to teeth Included Pre and post-natal complications Included Available only after 12 months membership Pregnancy and delivery up to *Dhs/QR 25,000, **Dhs/QR 25,000, OR 2,500 OR 2,500 Vaccination of a child member Dhs/QR 500, OR 50 No benefit (up to 6 years of age) up to Routine Dental Care up to Dhs/QR 2,000, OR 200 No benefit Available only after 9 months membership

Local Plan
Benefits Yearly maximum up to Outside area of cover Area of cover.

Please note: benefit values are reduced each time you claim only by the net amount (less any deductible, excess or co-insurance) we have actually paid. One of the A.G.C.C. countries Dhs/QR 300,000, OR 30,000 No benefit No benefit

Local

Daily accommodation charges Parent accommodation up to Cash benefit In-patient direct billing Level of cover

In-patient and daycare treatment

Level of reimbursement outside the A.G.C.C

Dhs/QR 500, OR 50 per night STAR & International Directory of hospitals 100% of the Reasonable & Customary (R&C) cost in the network shown. No benefit Dhs/QR 50, OR 5 DIAMOND Included Included Dhs/QR 500, OR 50 per night Included from enrolment

Included (single en-suite)

Applicable in-patient direct billing network Out-patient treatment

GP and Specialist consultation charges Courses of physiotherapy Out-patient direct billing

Per visit deductible (excess) applicable to all out-patient claims

Courses of chiropractic treatment, osteopathy, homeopathy and acupuncture up to

Applicable out-patient direct billing network Level of cover where your network is not available Health Screen up to Other benefits

Level of cover where your network is available

Available only after 9 months membership 100% of the Reasonable & Customary (R&C) cost in the network shown.

100% of the Reasonable & Customary (R&C) cost in the International Directory of Hospitals. No benefit

Pre-existing conditions up to Maintenance of non pre-existing Chronic Conditions up to Oral and maxillofacial surgery Ambulance transport Psychiatric treatment up to

Years 1 & 2: Dhs/QR 2,500, OR 250 Available only after 9 months membership Subsequent years: Dhs/QR 25,000, OR 2,500 No benefit Included Included Included

Years 1 & 2: Dhs/QR 2,500, OR 250 Available only after 9 months membership Subsequent years: Dhs/QR 5,000, OR 500

International Emergency Medical Assistance Accidental damage to teeth Pre and post-natal complications Vaccination of a child member (up to 6 years of age) up to
**Only available after 24 months membership.

Pregnancy and delivery up to Routine Dental Care up to

Included Available only after 12 months membership **Dhs/QR 25,000, OR 2,500 No benefit No benefit

Dhs/QR 5,000, OR 500

Any questions?

Will I be covered for any illnesses Ive had in the past? Yes, after nine months of membership, provided you declare on the application form any illness you have had in the past, we guarantee to cover related treatment up to the amount shown under the pre-existing condition benefit of your plan. This benefit applies after nine months of consecutive membership with us. Will I be covered for long-term illnesses? Yes, maintenance of chronic conditions is covered after nine months of consecutive membership up to the amount shown on your chosen plan under the Chronic Condition benefit. We treat cancer cases differently from other chronic conditions. Major treatment for cancer is covered in full under the main benefits of your plan.

Is there a dental benefit? Accidental damage to teeth is included on all our plans. Routine dental treatment is included under Global 1 and Regional 1 Plans. Please note that a co-insurance of 20% will apply to all eligible treatment.

Can you cover my children too? Yes, you can include any unmarried children under the age of 21 on your policy for an additional premium. When they reach 21 they will be required to take out their own policy.

Am I protected if I travel outside my chosen area of cover? If you choose the Regional Plans you will be covered outside your area of cover, excluding the USA, for emergency medical treatment. Please refer to the benefits table for the level of cover applicable to your chosen plan

How can I be sure that Im covered before I go ahead with treatment? Just ring our customer service team with the details of your proposed treatment. Theyll confirm your cover before you incur any treatment costs.

How do you define usual and customary? Within the AGCC, usual and customary is based on the average of our negotiated, discounted, costs within the network shown for your plan, STAR PLUS, STAR or DIAMOND network. Outside the AGCC, usual and customary is defined as the average, negotiated, discounted cost within the global network for that country or region. For example, in 2008, in the UAE, if your out-patient plan is based on the STAR network, we will reimburse up to 350 AED for a specialist and 250 AED for a general practitioner. If your out-patient plan is based on the DIAMOND Network, we will reimburse up to 180 AED for a specialist and 100 AED for a general practitioner. Will I be penalized if I go outside the AXA network? No additional penalty is applicable if you go outside the AXA network but we may not be able to settle the claim in full where the cost is higher than the usual and customary for your plan. Please note we may not always be able to arrange direct settlement facilities outside the network.

Do you always pay claims in full? All claims are paid on a usual and customary basis. If the cost for the treatment of your illness or injury is above the usual cost for the same treatment in the same area, we may not be able to settle the claim in full.

What is the AXA network in the AGCC? AXA works in the region with a wide network of high quality clinics and hospitals. These fall into three different categories referred to as STAR PLUS network, STAR network or DIAMOND network. Please contact us for further details.

Can I choose where I get treatment? Yes, you can visit any medical practitioner within your area of cover provided he is registered. You are free to go anywhere. We have contractual agreements with a number of medical centres where we have preferred rates. Use of the network applicable to your plan will minimise delays in settling any claims you may need to make.

Will you settle my claims on direct billing or reimbursement basis? Outside the AGCC For hospitalization, you have access to direct billing facilities within AXA PPP healthcares International Directory of Hospitals within your area of cover. Within your network in the AGCC During the first nine months, out-patient claims will be on reimbursement basis whether you are using the network or not. After nine months of consecutive membership, you are entitled to receive a new membership card giving you access to out-patient direct billing within the AXA network in AGCC. What happens if I move to another country? Contact us and we will, wherever possible, help you to transfer to another appropriate AXA PPP healthcare policy without any additional medical underwriting. The premium for each member depends upon their age. The sum of all those premiums is the total payable for the policy.
Up to 10 11 to 20 21 to 30 31 to 40 41 to 50 51 to 60 61 to 65
Age Age

Up to 10 11 to 20 21 to 30 31 to 40 41 to 50 51 to 60 61 to 65
Age

Age

Regional 1
Dhs/QR 3,962 3,740 4,246 4,972 6,827 8,662 10,866 Dhs/QR 2,905 2,743 3,114 3,646 5,196 6,280 7,878 Dhs/QR 2,177 2,055 2,333 2,731 3,750 4,656 6,309

OR 396 374 425 497 683 866 1,087 OR 291 274 311 365 520 628 788 OR 218 206 233 273 375 466 631

Regional 2

Table of prices

Up to 10 11 to 20 21 to 30 31 to 40 41 to 50 51 to 60 61 to 65

Global Area 1
Dhs/QR 14,869 14,041 16,089 18,025 27,382 38,046 50,576

OR 1,487 1,404 1,609 1,803 2,738 3,805 5,058 OR 482 455 590 666 940 1,180 1,479

If you are resident in Oman you are eligible for a 20% discount on the prices listed. If you are resident in Qatar you are eligible for a 15% discount on the prices listed. For individuals and Companies with fewer than 6 employees at inception.

Up to 10 11 to 20 21 to 30 31 to 40 41 to 50 51 to 60 61 to 65

Age

Local

Global Area 2
Dhs/QR 4,815 4,548 5,899 6,658 9,404 11,802 14,789

Up to 10 11 to 20 21 to 30 31 to 40 41 to 50 51 to 60 61 to 65

Membership is only available to UAE, Qatar and Oman residents who are under age 65 at the date on which their insurance cover starts. The annual premiums shown above include the 3% discount for annual payment.

Notes

Notes

Please Note: (i) NO LIABILITY WILL BE ACCEPTED FOR ANY MEDICAL CONDITION WHICH ORIGINATED BEFORE THE DATE OF ENROLMENT OR WHICH WAS FORESEEABLE AT THE TIME OF APPLICATION unless such medical condition has been declared to and accepted by AXA in writing. (ii) Failure to notify AXA Insurance of a medical condition may result in claims for benefit being refused or cover withdrawn. If you are in any doubt you should disclose the medical condition. Please ensure that you fully disclose any known or suspected conditions and symptoms experienced by anybody included in this application. This applies even if professional advice has not yet been sought. Typical examples are varicose veins, allergies, backache, foot disorders e.g. bunions, piles, gynaecological problems (including any irregularities of menstruation), complications of pregnancy, digestive irregularities, skin problems, trouble with heart, limbs, eyes, nerves etc any ear, nose or throat problems or any pains, swellings, lumps or fever.

7. Confidential medical history

(Declarations must be made in writing on this application. Verbal declarations WILL NOT be accepted)

Part A

You must declare your medical history even if you have been insured with us or anyone else before.
Name

Applicant

1st Family member

2nd Family member

3rd Family member

4th Family member

Please consider the following six questions as they apply to each of the people named. Answer each question by clearly ticking one of the corresponding Yes/No boxes. Name Name Name Name Yes 1. Has any in-patient stay in a hospital or nursing home taken place within the last five years? 2. Has any specialist/medical practitioner been consulted within the last five years? 3. Have you experienced any symptoms but not consulted a medical practitioner in the last five years? 4. Has any medical practitioner been consulted and/or provided prescriptions for any drugs or medication within the last two years? 5. Does any chronic/long-term medical or dental condition exist or has there been any other known disability, abnormality or recurrent illness or injury during the last five years? 6. Is there any known or foreseeable need to consult any doctor or other health professional? No Yes No Yes No Yes No

Yes

No

If there is any major condition falling outside the 5 year period mentioned above that we should know about, in good faith you must declare it.

Part B

1. Name of patient:

(Please use block capitals throughout).

2. Relevant 3. Nature of illness/disability and 4. When did it start: 5. How long 6. Need for any further 7. Present state section of Part A: treatment received: did it last: treatment or consultation: of health in this Month Year Duration respect:

Please continue on a separate sheet if necessary. This part applies if you have indicated Yes replies in Part A. Please disclose all medical conditions (or undiagnosed symptoms) to which these replies are intended to apply. Use column 3 to list them separately and give the further detailed information required by columns 4 to 6.

8. Your signature and declaration


Declaration: I declare that to the best of my knowledge and belief the statements on both sides of this application form are full, true and correct, that I shall read the AXA Insurance Healthcare Series Membership Agreement when received and that I agree to be bound by it. In the event of any dispute I agree to follow the AXA insurance (Gulf) B.S.C(c) arbitration process in the first instance. I agree that the acceptance of my application shall be on the basis of these statements. I agree that AXA may contact my/our medical practitioner(s) for further details of my/our medical history and authorise such practitioner(s) to release any information AXA may require.

#
Signature: Print name:

#
Date:

#
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 please let us know within three months. After completing this application form and signing the Declaration, please return it to your nearest AXA office IN THE AGCC or broker office if you are using one.

Credit Card Authorisation Form


To AXA Insurance Dept. I authorise you to charge my Credit Card Account an appropriate amount in respect of premiums for my subscription. AXA Membership Number Please complete in Block Capitals (to be completed by AXA) Please tick as appropriate: MasterCard Visa Name (as it appears on your credit card) My credit card number is: Expiry date: Signature # Date # Please charge the above credit/charge card Annually Half yearly

Please complete this form using Block Capitals and by ticking the relevant boxes. It is important that you provide the following information so that we can properly assess your application. If, therefore, you do not answer the questions we shall take that failure to answer to mean that you have nothing to disclose. This application must be completed by you or your parent/legal guardian in your/their own handwriting. If you need to make a correction, please initial the change.
Agents signature: Print name: Agency Code:

Please attach a Insured by current passport photograph for each person covered by this application. Please write the individuals name on the reverse of AXA INSURANCE (Gulf) B.S.C(c) the photo.

AXA International Healthcare Series


AXA HEALTHCARE

Re-insured by

For official use only. Date received

Application form

1. Your personal details (please keep us informed of any change of your address)
month year

Title: Full forenames: Address: Email Telephone number: Occupation: Nationality: Country where you are residing for most of the year: If you have ever been a member, or applied for membership of an AXA or AXA healthcare scheme, you must declare it. I have previously applied AXA Cover will commence when we have received your written acceptance of any underwriting terms and you premium. Number: Scheme name: Surname: Date of birth:
Day Month Year

Surname: Date of birth: day

Passport number: Fax number: Name of company/employer: Mobile number:

2. Your choice of Plan


Global 1 I am a previous member AXA healthcare Global 2 Regional 1 Regional 2 Local

3. Existing or any previous membership number

4. Additional family members to be covered


1 Relationship to you:
(wife/husband, son/daughter)

Date: Nationalilty: Passport number: Residing in:

Title: Membership number:

First name and other initials:

2 Relationship to you:
(wife/husband, son/daughter) Day Month Year

Title: Date of birth:

First name and other initials:

Surname: Membership number: Passport number:

Nationalilty: Residing in:

3 Relationship to you:
(wife/husband, son/daughter) Day Month

Title: Date of birth:


Year

First name and other initials:

Surname: Membership number: Passport number:

Nationalilty: Residing in:

4 Relationship to you:
(wife/husband, son/daughter) Day

Title:

First name and other initials: Date of birth:


Month Year

Surname: Membership number: Passport number:

Nationalilty: Residing in:

5. Method of payment
Half yearly* Dirhams If paying by credit card please complete and sign the credit card authorisation overleaf. Annually

tick one box only

6. Medical practitioner(s) most frequently used in the last 5 years


Name: Address:

*Please note, half yearly payment can only be made by cheque. We will require a post-dated cheque for the second half of the half yearly payment option at the same time as your first premium payment.

For AXA use only (Underwriting terms pertaining to this application)

Please continue on an additional sheet if required.

Telephone number

Fax number

Underwriter's stamp AXA Use Only. Membership number

Underwriting terms accepted by applicant Yes No

If the above details are different for any additional persons please list on a separate sheet.

Authorised signature: Print name: Date:

AXA Use Only. Effective date