international health insurance application form resident application.pdf · s t a n d: 2 1. 1 0. 2...

International Health InsuranceApplication Form

Please send the Application Form to us:

by Fax:+49 7628 803 336

or by E-Mail:[email protected]

or by Postal Mail:OSD International GmbH & Co. KG

Im Martelacker 8D-79588 Efringen-Kirchen

Germany

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BDAE Expat GmbH Kühnehöfe 3 • 22761 Hamburg • Germany

Registered office of the Company: Hamburg • HRB 122052 Local court of Hamburg • Managing Director: Philipp Belau

Phone: +49-40-30 68 74-0 Fax: +49-40-30 68 74-90

E-mail: [email protected] Web: www.bdae.com

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In order to provide for a smooth processing of your insurance application, we kindly ask you to observe and check the following points:

One more recommendation: If we have any further questions with respect to the information to be rendered by you we kind-ly ask you to answer them within the terms set forth by us so that your insurance coverage can commence on the desired date.

Thank you very much for your cooperation!

IMPORTANT INFORMATION FOR FILING APPLICATIONS

All information has been given completely and in block letters.

The instructions on legal rights have been signed.

The consent to the collection and use of health data has been signed.

The signatures of the applicant as well as of all persons of legal age to be insured have been made.

All information on payment modalities has been given and all required signatures have been made.

The health certificate has been drawn up in a clearly legible manner in the German or English language and all nec-essary signatures of the examining physicians have been made.

Each individual question has been answered.

Questions answered with “yes” or questions indicating a diagnostic finding have been explained in more detail.

For the supplementary modules EXPAT GERMANY PLUS, EXPAT RETIRED TOP or for conclusions of EXPAT RESIDENT a dental status has been prepared.

The name and the complete address of the treating primary physician have been indicated.

For the case that inpatient treatments (hospital stays) have taken place, the findings report and the discharge re-port have been attached to the application.

Completion of Application Documents

Completion of the Health Certificate

With respect to the insurance products EXPAT GERMANY, EXPAT PRIVATE Premium, EXPAT INFINITY as well as EXPAT RESIDENT and EXPAT RETIRED, please note as follows:

� EXPAT GERMANY: In the event that the person to be insured has, upon commencement of insurance coverage, already stayed in Germany for a period of more than 31 days, a health certificate or evidence supporting a German prior insurance must be submitted. At the time of application, the health certificate must not be older than 14 days.

� EXPAT PRIVATE Premium: Information on the state of health must be submitted together with the application. As from an age of 50 years, a health certificate that must not be older than three months at the time of application is to be filed.

� EXPAT INFINITY, EXPAT RESIDENT und EXPAT RETIRED: Information on the state of health must be submitted together with the application. As from an age of 60 years, a health certificate that must not be older than three months at the time of application is to be filed.

Stand: 21.10.2019

l BDAE EXPAT GMBH lKühnehöfe 3 l 22761 Hamburg

Phone: +49-40-30 68 74-0 l Fax : +49-40-30 68 [email protected] l www.bdae.com

Registered office of the company: Hamburg l HRB 122052 l Local court of Hamburg l Managing Director: Philipp Belau

HEALTH INSURANCE FOR PERSONS LIVING ABROAD

APPLICANT / PARTY ENTITLED TO INSURANCE:

Surname: First name(s): Current occupation:

BDAE membership no., if existing:

Address:

Phone: Fax: e-mail:PAYMENT DETAILS:

Payment type*:

Credit Card (+6%)*: oMaster-/Eurocard oVisa oDiners Valid until: Card no.:

Account / Card holder, if not applicant (please also sign below):INFORMATION ON ADDITIONAL HEALTH INSURANCE:

Do you have additional health insurance*? Insurance no.:THE FOLLOWING PERSONS ARE TO BE INCLUDED IN THE INSURANCE: (Please consider applicant)

Surname,

First name(s) Nationality

(*please tick)

I / we hereby apply for insurance cover as outlined by the terms and conditions for limited health insurance and sickness daily allowance cover of the EXPAT-series for

long-term journeys Part I and Part II (EXPAT RESIDENT tariff) for the persons listed above by registering them with the insurer as insured persons.

The total premium must be paid in advance in accordance with the chosen payment method.

I hereby give authorization to BDAE Holding GmbH to debit the premiums from my account or credit card (see above). As service provider of the BDAE Expat GmbH

the BDAE Holding GmbH is authorized to administer its contracts to the full extend and to collect debts. The debit will be assignable by the Creditor Identifier

DE23ZZZ00000131378. The individual mandate reference will be disclose on the Confirmation of Insurance Coverage. I hereby authorize my bank to redeem the debit

notes presented by BDAE Holding GmbH for the benefit of the insurer. Note: the premium is due after confirmation of insurance cover has been received and no later

than the beginning of the insurance. I / we am / are aware that the policy holder will not register the listed persons as insured persons with the insurer or will termi-

nate their registration if the premium or other charges have not been paid in full due to the actions of parties entitled to insurance. I / we am / are also aware that we

do not have insurance cover in this case.

Place, date:

Insurer: Würzburger Versicherungs-AG

Policy holder: BDAE EXPAT GmbH

Sex*

m f

Date

of birth

Planned country

of residencei

Monthly

premium

(EUR)

Start of

insurance

(Month / Year)

BIC / SWIFT-Code:Bank: IBAN:

Signatures:

(applicant or legal guardian of persons who are to be included in the insurance and all adults to be insured and

possibly different account holder / card owner)

oannually oevery six months (+2%) oquarterly (+3%) omonthly (+5%)

oNo oYes, with:

APPLICATION EXPAT RESIDENT

Jonas

Stempel

OSDI

Typewritten Text

VM: M59069.17230



Phone: +49-40-30 68 74-0 Fax: +49-40-30 68 74-90


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SEPA DIRECT DEBIT MANDATE

I hereby authorise BDAE Holding GmbH, in turn authorised by BDAE Expat GmbH for contract management and collec-tion, to collect payments owed by me from my account by means of direct debiting.

At the same time, I instruct my financial institution to honour direct debits drawn by BDAE Holding GmbH for the insurer.

Collection shall be identifiable on the basis of the Creditor Identifier DE23ZZZ00000131378 and the personal manda-te reference number shown in the confirmation of cover. Depending on the chosen payment method, collection shall take place on the 1st day of each month.

Please note: I shall be entitled to request the refund of the debited amount within a term of eight weeks commencing on the date of debiting. In this context, the terms and condi-tions agreed upon with my financial institution shall apply.

In the event that the funds on my account are insufficient, the financial institution in charge of my account shall not be obliged to honour the direct debit. Partial payments shall be excluded from direct debiting procedures.

In addition, the following regulations shall apply:

• Depending on the payment method elected below, the total amount shall be paid in advance in each case.

The person owing the premiums shall, towards the policyholder, be the person entitled to be insured and, towards the insurer, the policyholder.

• The premium shall be due for payment after receipt of the confirmation of cover, but in no case later than as to the inception date. I am aware that the policyholder will refrain from registering or will deregister the aforemen-tioned persons as insured persons with the insurer if the amount to be paid, inclusive of ancillary costs, fails to be paid or to be paid completely for reasons the person entitled to be insured is to be made responsible for. I am aware that no insurance coverage shall exist in such case.

• In the event that the person paying the premium is not identical with the person entitled to be insured / the insured person, the person entitled to be insured / the in-sured person shall be obliged to give the premium-paying person notice of the rendered information.

• Advance information on the collection of the owed amounts shall be given in the confirmation of cover addressed to the person entitled to be insured. In this context, the premium amounts, the due dates, the Credi-tor Identifier and the mandate reference number shall be indicated.

Applicable to premiums as from (dd/mm/yyyy)

Information on the person paying the premium

Surname Sex m f

First name(s)

Complete Address

Phone

IBAN

BIC/SWIFT Bank

Payment method annually twice a year (+ 2 %) quarterly (+ 3 %) monthly (+ 5 %)

Information on the insured person

Surname (if different from the person pay-ing the premium)

Sex m f

First name(s) (if dif-ferent from the person paying the premium)

Date of birth (dd/mm/yyyy)

Insurance number(s) (if available)

Place, date Signature of Account Holder




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HEALTH INSURANCE FOR PERSONS LIVING ABROAD

(*please tick)

With our signature we confirm that we have read and understood the following limitation:

No insurance cover is granted for temporary stays in the native country that last longer than six months per insurance year. This also applies if the six-month limit is

exceeded due to unexpected illness. (Exception: family members who are included in this insurance and who are nationals of the country of residence also have insur-

ance cover at home).

My / our insurance broker has advised me not to cancel existing insurances which apply at home or to join the public health scheme of your home country or - if pos-

sible - to apply for additional insurance cover.

Place, date

Insurer: Würzburger Versicherungs-AG

Policy holder: BDAE EXPAT GmbH

(applicant or legal guardian of persons who are to be included in the insurance and all

adults to be insured)


Surname: First name(s): Current occupation:THE FOLLOWING PERSONS ARE TO BE INCLUDED IN THE INSURANCE: (Please consider the applicant!)

Surname,

First name(s)

Nationality

m f

Date of birth

Commencement

of insurance

(Month / Year)

Signatures:

Sex*

ADDITIONAL DECLARATION FOR THE EXPAT RESIDENT APPLICATION

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Phone: +49-40-30 68 74-0 Fax: +49-40-30 68 74-90


WÜRZBURGER VERSICHERUNGS-AGLegal Instructions

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by Würzburger Versicherungs-AG (Insurer) as per Section 19 Paragraph 5 Sentence 1 of the German Contract Insurance Act (VVG)

LEGAL INSTRUCTIONS

Information as per Section 19 paragraph 5 of the German Contract Insurance Act (VVG) about the Consequences of an Infringement of Statutory Reporting Duties

In order to enable the Insurer to properly review your application, you are requi-red to give true and complete answers to the questions asked in the application documents. Circumstances considered by the applicant as being of little import-ance must also be reported. Any information you do not want to render to the insurance broker is to be directly reported in writing to the Insurer without any delay. Please note that you put your insurance cover at risk whenever you render incorrect or incomplete information. For more details on the consequences of an infringement of reporting duties, reference is made to the following information.

Are there Pre-Contractual Reporting Duties?

Until the time of submitting your contract declaration, you shall be obliged to give the Insurer correct and complete notice of any and all risk-relevant circums-tances known to you and requested by the Insurer in text format. Risk-relevant circumstances are circumstances having significance for the Insurer’s decision to conclude the contract with the contents agreed upon. Risk-related circumstances requested by the Insurer after your contract declaration, but prior to contract acceptance by the Insurer must also be reported.

What are the Possible Consequences of an Infringement of the Pre-Contractual Reporting Duty?

1. Rescission of Contract and Loss of Insurance Cover

In the event that you and/or the person to be insured fails to comply with the pre-contractual reporting duty, the Insurer shall be entitled to rescind the contract, unless you are able to provide evidence that you did not infringe the reporting duty with intention or with gross negligence. In the event of a grossly negligent infringement of the reporting duty, the Insurer shall not be permitted to rescind the contract if the contract would also have been concluded by the latter, even if under different terms and conditions, had the Insurer been aware of the undisclosed circumstances. In the event of a rescission, insurance coverage shall cease to exist. If the Insurer rescinds the contract after occurrence of an insured event, the Insurer shall continue to be obliged to pay compensation if you are able to provide evidence that the circumstance that failed to be reported or to be correctly reported by you has neither been the cause for the occurrence or determination of the insured event nor for the determination or volume of the duty to indemnify. The Insu-rer’s duty to indemnify shall, however, cease to exist if the reporting duty has been violated by you with fraudulent intent. In the event of a rescission due to an infringement of the reporting duty, the Insurer shall be entitled to receive insurance premiums until the rescission becomes effective.

2. Cancellation

In the event that the Insurer is not permitted to rescind the contract due to the absence of intention or gross negligence on your part when you failed to comply with your reporting duty, the Insurer shall be entitled to terminate the contract by observing a notice period of one month. The Insurer’s right to terminate shall be excluded if the contract would also have been concluded by the latter, even under different terms and conditions, had it been aware of the undisclosed circumstances.

3. Amendment of Contract

If the Insurer is not permitted to rescind or terminate the contract because it would have had concluded the contract also in knowledge of the undisclo-sed risks, even if under different terms and conditions, the other terms and conditions shall upon the Insurer’s request retroactively become a part of the contract if you negligently violated the reporting duty. If the premium is, due to the contract amendment, increased by more than 10% or the Insurer

excludes the coverage of the risk related to the undisclosed circumstance you shall be entitled to terminate the contract with immediate effect within one month after having received the respective notice of the Insurer about the contract amendment. The Insurer shall draw your attention on this right in its notification.

4. Execution of the Rights of the Insurer (Section 21 of the German Insurance Contract Act (VVG))

The Insurer shall be entitled to assert its rights of rescission, cancellation or contract amendment in writing within a term of one month. Said term shall commence on the date on which the Insurer becomes aware of the infringement of the reporting duty underlying the right asserted by it. When executing its rights, the Insurer shall indicate the circumstances relied on in this context. As long as the time period according to sentence 1 has not yet expired, the Insurer may in support of its decision also indicate additional circumstances at a later time. The Insurer shall not be permitted to rely on the rights of rescission, cancellation or contract amendment if it was aware of the undisclosed risk or the incorrectness of the reported information. Its rights of rescission, cancellation or contract amendment shall terminate upon expiry of three years after contract conclusion. This shall not apply to insured events occurred prior to the expiry of said time period. In the event that you infringed the reporting duty intentionally or fraudulently, the period shall be extended to ten years.

5. Fraudulent Misrepresentation (Section 22 of the German Insurance Contract Act (VVG))

The Insurer’s right to contest the contract on the grounds of fraudulent misre-presentation shall remain unaffected.

6. Representation by another Person (Section 20 of the German Insurance Contract Act (VVG))

In the event that you have yourself represented by another person when con-cluding the contract, both the knowledge and fraudulent intent on the part of your representative and your own knowledge and fraudulent intent shall be taken into account with respect to the reporting duty, the rescission, cancella-tion, contract amendment and the deadline for the execution of the Insurer’s rights. A reliance on an absence of intention or gross negligence when failing to comply with the reporting duty may only be relied on when neither your representative nor you can be made liable for intention or gross negligence.

Place, date Signatures (Applicant, if appropriate as legal representative of persons to be co-insured and all persons of full legal age to be insured)

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Registered office of the company: Hamburg • HRB 122052 Local court of Hamburg • Managing Director: Philipp Belau

Phone: +49-40-30 68 74-0 Fax : +49-40-30 68 74-90


WÜRZBURGER VERSICHERUNGS-AGConsent

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to the Collection and Use of Health Data and Declaration of Release from Secrecy towards Würzburger Versicherungs-AG (Versicherer)

The declarations of consent and release from secrecy according to Part I. were prepared on the basis of the coordination process between the Gesamtverband der deutschen Versicherungswirtschaft e.V. (GDV) and the data protection supervisory authorities.

CONSENT

Part I - Statement upon Application

The German Insurance Contract Act, the Federal Data Protection Act as well as ot-her data protection regulations do not provide for an adequate legal basis for the collection, processing and use of health data by insurance companies. In order to be able to obtain and use your health data in connection with this application and the contract, we therefore need your consent(s) according to data protection regulations. In addition, Würzburger Versicherungs-AG is in need of your state-ments of release from secrecy in order to be able to obtain your health data from parties subject to secrecy such as, for instance, physicians.

As health insurance company, Würzburger Versicherungs-AG needs your state-ment of release from secrecy also in order to be able to disclose your health data or any other data protected according to Section 203 StGB [German Criminal Code] such as, for instance, the fact that a contract has been concluded with you, to other entities or parties such as e.g. assistance, reinsurers.

The following statements of consent and release from secrecy are indispensable for checking your application and for concluding, implementing or terminating your insurance contract for Würzburger Versicherungs-AG. If you fail to make such statements, the conclusion of a contract will, as a rule, not be possible.

The statements relate to the handling of your health data and other data protec-ted according to Section 203 StGB

• on the part of the Würzburger Versicherungs-AG itself (see clause 1.);

• in connection with enquiries addressed to third parties (see clause 2.);

• when disclosing data towards entities or parties outside Würzburger Versiche-rungs-AG (see clause 3.), and

• if the contract fails to come into being (see clause 4.).

These statements will apply with respect to co-insured persons legally represen-ted by you, such as your children, to the extent that they are not able to recognise the significance of this consent and are therefore not able to make statements on their own.

1. Collection, storage and use of health data provided by you on the part of Würzburger Versicherungs-AG

I agree that Würzburger Versicherungs-AG collects, stores and uses the health data provided by me in connection with this application as well as in future to the extent that this is necessary for the examination of my ap-plication and for concluding, implementing and terminating this insurance contract.

2. Request for information on health issues from third parties

2.1 Request for health data from third parties for risk assessment and verification of the duty to indemnify

For assessing the risks to be insured, it may become necessary to obtain infor-mation from entities or parties retaining health data concerning your person. In addition, it may become necessary for Würzburger Versicherungs-AG to check the information on your health condition, as rendered by you for sub-stantiating your claims or as it can be derived from submitted documents (e.g. invoices, prescriptions, expert reports) or information rendered by, for instan-ce, a physician or other members of the medical profession, in order to verify its duty to indemnify. Such examination shall be carried out to the necessary extent only. Würzburger Versicherung-AG needs your consent thereto, inclu-sive of a release from secrecy for itself as well as for these parties for the case that health data or other information protected according to Section 203 StGB must be forwarded within the framework of such requests.

You may make these statements already here (I) or at a later time with respect to an individual case (II). You may change your decision at any time. Please select one of the following two options:

Option I:

I agree that - to the extent necessary for risk assessment or verification of the duty to indemnify - Würzburger Versicherungs-AG collects my health data from physicians, caregivers as well as employees in hospi-tals, other health institutions, care homes, personal insurers, statutory health insurance funds, trade associations and public authorities and uses them for these purposes.

I release the indicated persons and employees of the aforementioned institutions from their secrecy duties to the extent that health data permissibly stored with respect to my person and arising from exami-nations, consultations, treatments as well as insurance applications and contracts made during a period of up to ten years prior to the date of my application are disclosed towards Würzburger Versicherungs-AG.

In addition, I agree that in this context my health data are - to the extent necessary - disclosed by Würzburger Versicherungs-AG towards these parties or entities and, to this extent, also release the persons becoming active for Würzburger Versicherungs-AG from their secrecy duties.

Prior to every data collection according to the preceding paragraphs, I will be informed about the persons by whom and the purpose for which data are planned to be collected, and furthermore about the fact that I may raise objections and submit the required documents on my own.

Option II:

I want Würzburger Versicherung-AG to inform me in each individual case from which persons or entities and for what purpose information is required. Afterwards, I will decide whether I

• agree to the collection and use of my health data by Würzburger Versicherungs-AG, release the indicated persons or entities and their employees from their secrecy duties and agree to the disclosure of my health data to Würzburger Versicherungs-AG

• or whether I want to submit the required documents myself.

I am aware that this may result in a delay of application processing or the verification of the duty to indemnify. To the extent that the aforementioned declarations relate to my statements at the time of application, they shall be valid for a period of five years after contract conclusion.

If, after contract conclusion, Würzburger Versicherungs-AG becomes aware of specific circumstances indicating that, at the time of applicati-on, incorrect or incomplete information was deliberately furnished and, as a result, influence was exerted on risk assessment, the statements shall be valid for a term of up to ten years after contract conclusion.

2.2 Statements for the event of your death

In order to verify our duty to indemnify, it might become necessary to check health data even after your death. An examination may also become neces-sary if, up to a period of ten years after contract conclusion, Würzburger Ver-sicherungs-AG becomes aware of circumstances indicating that incorrect or incomplete information might have been rendered at the time of application and that, hence, influence was exerted on risk assessment. For this purpose, too, we need a consent and a statement of release from secrecy. Please select one of the following two options:

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Registered office of the company: Hamburg • HRB 122052 Local court of Hamburg • Managing Director: Philipp Belau

Phone: +49-40-30 68 74-0 Fax : +49-40-30 68 74-90


WÜRZBURGER VERSICHERUNGS-AGConsent

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Option I:

For the case of my death, I give my consent to a collection of my health data from third parties for the purpose of verifying a duty to indemnify or for examining the application again, if necessary, as described in the first checkbox (see above 2.1. - Option I).

Option II:

If, after my death, health data must be collected in order to verify a duty to indemnify or to examine the application again, my heirs or - if different - the beneficiaries of the contract shall be authorised to deci-de upon consents and statements of release from secrecy.

3. Disclosure of health data and other data protected according to Section 203 StGB to entities or parties outside Würzburger Versicherungs-AG

Würzburger Versicherungs-AG contractually obliges the following entities or parties to comply with the provisions on data protection and data security.

3.1 Disclosure of data for medical assessment

In order to assess the risks to be insured and to verify the duty to indemnify, it may become necessary to involve medical experts. Würzburger Versiche-rungs-AG is in need of your consent and statement of release from secrecy if, in this context, your health data and other data protected according to Section 203 StGB are disclosed. You will be given notice of the respective data disclosure.

I agree that Würzburger Versicherungs-AG transfers my health data to me-dical experts if this is necessary within the framework of risk assessments or verifications of the duty to indemnify and that my health data are used there according to the purpose of the transfer and that the results are sent back to Würzburger Versicherungs-AG. With respect to my health data and other data protected according to Section 203 StGB, I release the persons active for Würzburger Versicherungs-AG and the experts from their secrecy duties.

3.2 Delegation of tasks to other entities or parties (business ent-erprises or persons)

Some tasks such as, for instance, risk assessments, processing of submit-ted claims or customer service by phone, which may involve the collection, processing and use of your health data, are not carried out by Würzburger Versicherungs-AG itself, but instead delegated to another entity or party. If, in this context, your data protected according to Section 203 StGB are disclosed, Würzburger Versicherungs-AG needs your statement of release from secrecy for itself and, where appropriate, for the other entities or parties.

BDAE Expat GmbH as policyholder maintains a constantly updated list where the entities/parties and categories of entities/parties contractually engaged in collecting, processing or using health data for BDAE Expat GmbH and Würz-burger Versicherungs-AG as well as the delegated tasks are indicated. The currently valid list is available on the Internet under www.bdae.com/images/forms/docs/en/List_of_service_providers.pdf or can be obtained from the data protection officer of the BDAE Group, HUBIT e.K., Postfach 610120, 28261 Bremen, e-mail: [email protected]. In order to be able to disc-lose your health data towards the entities/parties mentioned in this list and to have them processed your data, we and Würzburger Versicherungs-AG are/is in need of your consent.

I agree that Würzburger Versicherungs-AG discloses my health data towards the entities/parties indicated in the aforementioned list and that the health data are collected, processed and used there for the indicated purposes to the same extent as Würzburger Versicherungs-AG would be allowed to do. To the necessary extent, I release the employees of Würzburger Versicherungs-AG and other parties or entities from their secrecy duties with respect to the disclosure of health data and other data protected according to Section 203 of the StGB.

3.3 Data disclosure to reinsurers

For the purpose of safeguarding your claims, Würzburger Versicherungs-AG may involve reinsurers who assume the risk either totally or in part. In some instances, the reinsurers make use of other reinsurance companies for such purposes so that your data will also be disclosed towards such other reinsurance companies. In order to enable the reinsurers to get their own impressions of the risk or insured event, Würzburger Versicherungs-AG might submit your application form or claims for payment of benefits to the reinsu-rance companies. This will particularly be the case when the insurance sum is especially high or the risk is difficult to assess. Moreover, it is possible that the reinsurance company renders assistance to Würzburger Versicherungs-AG on the basis of its special expertise during the risk assessment process or verification of the duty to indemnify as well as during the assessment of process sequences. If reinsurers have hedged the risk, they can monitor whether Würzburger Versicherungs-AG has assessed the risk or an insured event correctly. In addition, data on your existing contracts and applications are disclosed towards reinsurers to the required degree so that they are able to check whether and to what amount they can participate in the risk. Data on your existing contracts may be forwarded to reinsurers for the purpose of billing premium payments and settling insured events. For the aforemen-tioned purposes, anonymised or pseudonymised data, if possible, but also personal health data will be used. A use of your personal data by reinsurance companies will be limited to the aforementioned purposes. Würzburger Ver-sicherungs-AG will give you notice about a disclosure of your health data to reinsurers.

I agree that my health data are - to the necessary extent - forwarded to reinsurers and used by them for the indicated purposes. I release persons active for Würzburger Versicherungs-AG to the necessary extent from their secrecy duties with respect to health data and other data protected according to Section 203 StGB.

3.4 Disclosure of data to self-employed intermediaries

As a rule, Würzburger Versicherungs-AG does not disclose data on your health state to self-employed intermediaries. In the following events, howe-ver, data permitting conclusions on your health or information on your con-tract, as protected according to Section 203 StGB, might be disclosed towards insurance intermediaries for information purposes. To the extent required for contract-related consultation purposes, the intermediary supporting you might receive information on the fact whether and, when appropriate, under what conditions (e.g. acceptance of a risk markup, exclusion of certain risks) your contract can be accepted. The intermediary having submitted your contract will get knowledge of a contract conclusion and its content. In this context, the intermediary will also be informed whether risk markups or exclusions of certain risks have been agreed upon. If you change the inter-mediary supporting you, the contract data containing the information on risk markups and exclusions of certain risks may be disclosed towards the new intermediary. When you change the intermediary who supports you we will give you notice of the disclosure of health data towards the new agent and of your possibility to raise objections.

I agree that, in the aforementioned events, Würzburger Versicherungs-AG discloses my health data and other data protected according to Section 203 StGB to the required extent towards the self-employed insurance in-termediary who is in charge of my affairs and that such data are collected, stored and used there for consultation purposes.

4. Storage and use of your health data if the contract fails to come into being

If a contract with you fails to come into being, Würzburger Versicherungs-AG will retain your health data collected within the framework of the risk assess-ment for the case that you apply for insurance coverage again. Würzburger Versicherungs-AG will also store your data in order to give a reply to enquiries, if any, by other insurance companies. Your data will be stored by Würzburger Versicherungs-AG until expiry of the third calendar year after the year of application.

I agree that Würzburger Versicherungs-AG may, for the aforementioned purposes, store and use my health data in case that the contract fails to come into being for a period of three years after the expiry of the calendar year during which the application was filed.

Place, Date Signatures (Applicant), if appropriate as legal representative of persons to be co-insured and all persons of full age to be insured)

https://www.bdae.com/images/forms/docs/en/List_of_service_providers.pdf

https://www.bdae.com/images/forms/docs/en/List_of_service_providers.pdf

mailto:datenschutz%40bdae.com?subject=

Stand: 21.10.2019




EXPAT RESIDENT


Surname: First name(s):

Please answer all the questions below. Please also include ailments which you regarded as unimportant or which you did not view as illnesses, even if you did not receive

treatment, but only had an examination or test or only took medicines and were not incapacitated. If you supply incorrect or insufficient information you may loose

your insurance cover.SECOND PERSONFIRST PERSONDETAILS ABOUT INSURED PERSONS:

The following questions must be answered for each insured

person listed in the application according to the information

supplied by the insured persons. In the case of minors, the

questions must be answered in accordance with the informa-

tion supplied by the guardian.

If there are more than two insured persons, please use addition-

al copies of this form.

Surname:

First name(s):

Date of birth:

Size:

Weight:

cm

kg

cm

kg

1. Do you currently suffer from ailments, illnesses, the effects of an accident,

physical or mental disorders? (including teeth)2. Have you been taking medicines, alcohol or drugs on a daily or almost daily

basis for the last five years?3. Is an examination, check-up, treatment or operation required at this time?

Please also supply information on dental treatments, dentures, orthodontic

measures, or paradontosis treatments.4. Have you had inpatient or outpatient examinations / treatments or opera-

tions by doctors, dentists, healers, psychologists or masseurs or have you

been in hospital for the last five years? (Please also supply information about

cures and stays at sanatoriums).5. Do you have defective vision i.e. do you require glasses or contact lenses?

Please give details (dioptre number).

Please give details on the questions which you answered with "Yes" (state the person(s) and the number(s) of the questions / use an additional sheet of paper if necessary):

oYes oNo oYes oNo

oYes oNo oYes oNo

oYes oNo oYes oNo

oYes oNo oYes oNo

oYes oNo oYes oNo

Left: Right: Left: Right:

Insured

person

Question

no.

Detailed description of illness,

type of ailment

Treatment(s)

received inpatient / outpatient? Dates

Do you still

suffer from consequences?

If yes, please give details.

Please give the names of the doctors who can supply more detailed information. If all questions have been answered with "No", please indicate the name, specialist

field and exact address of the doctor who can supply the most up-to-date information.

First Person:

Second Person:

Place, date: Signature:

(applicant or legal guardian of persons who are to be included in the insurance and all

adults to be insured)

HEALTH DECLARATION TOWARDSWÜRZBURGER VERSICHERUNGS-AG (INSURER)




HEALTH CERTIFICATE FOR APPROVAL OF AN APPLICATION FOR HEALTH INSURANCE EXPAT RESIDENTEXAMINATION COSTS WILL BE BORNE BY THE APPLICANT! TO SUBMIT WITH AGE OF 60 AND ABOVE

Stand: 21.10.2019

HEALTH CERTIFICATE TOWARDS WÜRZBURGER VERSICHERUNGS-AG (INSURER)

1


Surname: First name(s): Date of birth:

Address:1. DECLARATION TO THE DOCTOR:

ANSWER IF YES: WHICH, TREATED WHERE (DOCTOR), DIAGNOSIS1.a Are you currently suffering from complaints,

illnesses or the results of accidents?

oYes oNo

1.b Do you or have you suffered from a chronic

or repetitious illness?

oYes oNo

1.c Have you been examined, advised or treated

by medical staff (e.g. doctors, consultants,

medical practitioners, psychologists, masseurs..)

in the last three years or have you been

unable to work - even temporarily?

oYes oNo

1.d Have operations or treatment been per-

formed, planned or advised?

oYes oNo

1.e Has hospital treatment (including clinics,

sanatoriums etc.) taken place in the last 5

years?

oYes oNo

1.f Have blood examinations been performed?

With which results?

oYes oNo

1.g Has an HIV infection been determined, e.g.

by an AIDS test?

oYes oNo

1.h Have you had or are you engaged in cytosta-

tic treatment?

oYes oNo

1.i Do you or have you regularly imbibed medi-

cines, alcohol or drugs?

oYes oNo

1.j Do you have impaired sight or do you re-

quire an aid to vision (e.g. spectacles, con-

tact lenses)? Dioptre?

oYes oNo

1.k Which doctor do you usually consult?

(Regular GP)1.l

1.m

Is dental treatment necessary, particularly

with regard to dentures, dental surgery or

parodontosis?

oYes oNo

Are you pregnant? oYes oNo

I hereby confirm with my handwritten signature that the above declaration is a part

of my application for health insurance and that the I have answered the above

questions dictated to me individually by the doctor personally and truthfully.

Place / Date:

Signature of the applicant: Anamnesis performed (Stamp / Signature of the doctor):

WHEN?

Stand: 21.10.2019

2


EXAMINATION DIAGNOSIS FOR:

2. GENERAL:ANSWER DIAGNOSIS / DEVIATIONS / EXPLANATION

2.a Have you examined, advised or treated the

person in the past?

oYes oNo

2.b Height:

Weight:

cm

kg2.c Do you consider the skeleton and locomo-

tion to be healthy?

oYes oNo

2.d Do you consider the skin, mucous mem-

branes and lymph glands to be healthy?

oYes oNo

2.e Do you consider the sensory organs to be

healthy?

oYes oNo

2.f Do you consider the nervous system and psy-

che to be healthy?

oYes oNo

2.g Are the reflexes normal? oYes oNo

2.h Do you consider the hormonal system to be

healthy?

oYes oNo

2.i Is the thyroid gland normally shaped? oYes oNo

3. CARDIOVASCULAR SYSTEM:3.a Pulse at rest

After 10 knee bends

Return to normal in minutes

mm Hg

mm Hg

Blood pressure at rest

After 10 knee bends

3.b

3.c Can unhealthy hear sounds be heard? oYes oNo

3.d Is the heart arrhythmic? oYes oNo

Is the heart enlarged or displaced? oYes oNo3.e

3.f Are there any signs of insufficiency? oYes oNo

3.g Does the patient have dyspnoea? oYes oNo

4. BLOOD VESSELS:4.a Is the patient oedemic? oYes oNo

4.b Does the patient have haemorrhoids, vari-

cose veins? (type? / extent?)

oYes oNo

4.c Does the patient have scars, ulcers?

(type? / extent?)

oYes oNo

5. RESPIRATORY ORGANS:5.a Does the patient suffer from hoarseness,

coughs, bronchitis? (since when? extent?)

oYes oNo

5.b Is the rib cage deformed? oYes oNo

5.c Are the results of the percussion and auscul-

tation examinations normal?

oYes oNo

5.d Do you consider die respiratory organs to be

healthy?

oYes oNo

6. DIGESTIVE AND ABDOMINAL ORGANS:6.a Signs of illness on the tongue, tonsils,

throat?

oYes oNo

6.b Are the examination results of the abdomen

normal?

oYes oNo

6.c Is the liver enlarged? oYes oNo

6.d Is the pancreas enlarged? oYes oNo

6.e Does the patient suffer from a rupture? oYes oNo

/

/

2.j Are you suspicious of an organic disorder? oYes oNo

Stand: 21.10.2019

f missing teeth e replaced teeth K crowned teeth b bridged teeth s teeth in need of rehabilitation )( space closure

3

ANSWER IF YES: WHICH, TREATED WHERE (DOCTOR), DIAGNOSIS9.a Are there gum diseases? oYes oNo

WHEN?9. DENTAL:

7.


URINAL AND SEXUAL ORGANS:

ANSWER

7.a Is the condition of the renal capsule normal? oYes oNo

DIAGNOSIS / DEVIATIONS / EXPLANATION

EXAMINATION DIAGNOSIS FOR:

7.b urine examination:

exterior condition:

pathological components:

protein

sugar

bile pigment high

oYes oNo

oYes oNo

oYes oNo

sediment:

7.c

8.8.a

8.b Are there signs of an immune disorder?

oYes oNo

oYes oNo

OTHER ASPECTS THAN THE EXAMINATION RESULTS ARE SOMETIMES DECISIVE IN THE EVALUATION OF THE RISK.PLEASE DO NOT DISCLOSE ANY INFORMATION OF THE INSURANCE RISK.

Regarding woman: Pregnancy? oYes oNo in ______ month

MISCELLANEOUS:What other disorders and still unnamed di-

agnoses were found?

Place / Date Stamp / Signature of the doctor

DETAILS OF THE DENTAL STATUS

DENTAL STATUSDIAGNOSIS OF ALL TEETH

DIAGNOSIS

DIAGNOSIS

DIAGNOSIS

DIAGNOSIS

18 17 16 15 14 13 12 11 21 22 23 24 25 26 27 28

48 47 46 45 44 43 42 41 31 32 33 34 35 36 37 38

DIAGNOSIS / LEGEND:

Stamp / Signature of the dentistPlace / Date

6.f Unhealthy diagnosis of the digestive organs? oYes oNo

Declarationthe insurance broker:

OSD International GmbH & Co. KG, Im Martelacker 8, 79588 Efringen-Kirchen, Germany-hereafter called ‚broker’-

and

Ms Mr Company

Name: _______________________ Adress: ______________________________________________hereafter called ‚Client’-

conclude the following agreement:

The client contacted the broker by own will, he was not acquired neither by the broker nor by thirdparties and exclusively ordered an offer for international health insurance. Consultation was done onlyvia telephone or email. The client decided to take out insurance of the provider BDAE. The clientexpressly foregoes the following services of the broker:

1. the detailed risk evaluation and the creation of a customer profle according to a need analysis and theassociated need determination

2. the full scope of market monitoring and market exploration based on the limited consultationdesired and accepted by the customer

3. the full scope of protocolling the consulting

The client confrms that he received suffcient consultation concerning the products mediated by thebroker. He was provided with the premium and tariff tables, lists of services and the insurance conditions ofthe selected tariff (and if applicable further alternative tariffs of other providers) prior to application. Theclient read these documents and understood them. He had suffcient time to review the offers and rethinkhis decision in every way. The broker is not able to consider possibly existing local conditions concerningpossible insurance obligations in his consultation. This is the client's responsibility alone. The client herebyrelieves the broker from any liability in the sense of the mediating and consulting performance. The clientwas provided with the business card of the broker prior to application (if applicable in electronic form). Theclient read and understood the below stated declaration.

The client accepts the brokers data protection guidelines which can be found onhttps://osdinternational.com. The client accepts that the broker will use and store the clients personal datato process the application and ongoingly serve the client as such. The client accepts that the broker willforward the clients personal information and all relevant documents to the insurer which the clientselected, by Post, electronically and/or over the phone. The client accepts that the broker may contact himwithout further request by Post, electronically and/or over the phone as part of his ongoing consultationservices regarding the selected insurance plan.

_______________________ _________________ _______________________Place Date Clients Signatue

DELCARATION: OSD International GmbH & Co. KG hereby declares that OSD has no direct or indirect participation of over 10% to the capital or thevoting rights of a certain insurance company. In addition, no insurance company holds shares of the OSD International GmbH & Co. KG in the abovedescribed manner. The OSD International GmbH & Co. KG also confirms that OSD is not contractually obligated to undertake insurance mediationservices with one or several insurance companies. OSD International GmbH & Co. KG possesses the legally prescribed limited liability insurance with thelegally set insurance sums.------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------

Location: Efringen-Kirchen - Manager: Steffen Dantz - registered at the District Court Freiburg i.Br.: HRA 704232 - Revenue Office Lörrach, Sales tax.-ID: DE266496030 - Mutual office in the sense of & 11 a GewO: DIHK e.V. - Breite Straße 29 - 10178 Berlin - Registration pursuant to & 1 1a GewO: D-LNF2-AAZ9E-10 - www.vermittlerregister.info - Responsible: IHK Hochrhein-Bodensee, Schützenstr. 8, 78462 Konstanz - Arbitration board: Versicherungsombudsmann e.V. - PF 080602 - D-10006 Berlin - Supervisory authorities: BAFin - Graurheindorfer Str. 108 - D-53117 Bonn - General partner: OSD Internional Verwaltungs- GmbH - Im Martealcker 8 - 79588 Efringen-Kirchen - Registered at the District Court Freiburg i.Br.: - HRB 713332 - Manager Steffen Dantz

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