COMPANY

HEALTH INSURANCE
APPLICATION

IMPORTANT INFORMATION
Please write clearly in black ink and BLOCK CAPITALS. Return this form to your company’s Bupa Global Group Administrator in a
sealed envelope. If you have any questions when completing this form, please call 16816 (inside Egypt) or
+202 2768 1100 (outside Egypt).
Checklist - please make sure:

If this is a new application If you are amending your existing application

 the information you have given in sections 2-6 is correct and complete  the information you have given in section 1-6 is correct and complete

 you have read, signed and dated the declaration in section 7  you have read, signed and dated the declaration in section 7

All sections which need to be completed by the main applicant are labelled 

TO BE COMPLETED BY YOUR COMPANY

Group name

Group number Cover start date D D M M Y Y Y Y

Product name

Purpose of application: New application Amendment to existing application

The options below will increase your premiums:

USA cover

Evacuation

Repatriation (automatically includes Evacuation cover)

 If this is a new application, start at section 2 If you are amending an existing application, start at section 1

1 EXISTING MEMBER: MEMBERSHIP DETAILS

Membership number BI - - - Date of birth D D M M Y Y Y Y

2 MAIN APPLICANT: YOUR PERSONAL DETAILS

Title Male Female

First name Middle initials

Last name

Date of birth D D M M Y Y Y Y Country of nationality

Do you have current health cover with any other insurer, including Bupa Egypt or Bupa? Yes No

Name of other health insurer

Name of plan/cover

Membership number

(please let us know straight away

3 MAIN APPLICANT: YOUR ADDRESS DETAILS about any change of address)

Residency address (your permanent or usual address in the country where you are resident, this should be the country in which you are living on the first day of your current membership year)

Address line 1

Address line 2

Town/city

State/emirate

Country

Postal / zip / area code

Correspondence address (where membership documents cannot easily be sent to you at your residency address, please supply an alternative address to which they may be sent)

Address line 1

Address line 2

Town/city

State/emirate

Country

Postal / zip / area code

4 MAIN APPLICANT: YOUR OTHER CONTACT DETAILS

(Please include country code, area code and number)

Phone/mobile

Phone/mobile

Email
5 MEDICAL QUESTIONS AND HISTORY
MAIN APPLICANT ONLY
Please answer each of these questions fully and accurately for the person named above. It is important to tell us about any known or suspected
medical conditions and symptoms, even if the applicant has not yet consulted a doctor about them. So you should include for example, any varicose
vein problems, ear, nose or throat problems and any pains, swellings or lumps. You should also include any symptoms/conditions for which remedies
are being taken, whether or not these are prescribed by a medical practitioner.
Please tick either Yes or No to each of these questions

1. Currently, is this person receiving treatment of any kind, eg receiving physiotherapy or taking medication?

2. Within the last six months, has this person experienced any signs or symptoms of any medical problem where you have not yet consulted a doctor/health professional?

3. Within the last four years, have you consulted a doctor/healthcare professional and/or been prescribed any drugs or medication?

4. Within the last four years, have you required assessment or treatment in a hospital or clinic, as a day case, emergency or in-patient?

5. Does this person have any medical devices or implants in your body eg heart pacemaker, artificial joint, or any internal fixation such as pins/plates or screws?

6. Does this person suffer from any chronic/long term medical or dental conditions or have any disability, abnormality, recurrent illness or injury?

7. Does this person require any consultations with a healthcare professional, tests, medication or treatment for any past or current medical problem?

This section applies if you have indicated ‘Yes’ to any medical questions. If you are unsure whether any details are relevant, you must include them.
Question What was the condition (or symptom When were symptoms first What was the treatment/ What was the outcome of the
number if not yet diagnosed)? experienced and when was medication (including dates and treatment (eg full recovery, ongoing
If applicable, state the area affected treatment completed (if names)? treatment required, likely to recur or
eg right leg. applicable)? awaiting test results)?

If you do not provide us with full details we may terminate your cover or it may stop us from paying your claims.

If there is insufficient space, please use a separate sheet and indicate that you have done so by ticking here:

Please tell us immediately if you or any additional people to be covered under the plan experience any symptoms before you
receive your membership documents. Failure to do so may mean we are unable to pay your claims.
6 MEDICAL QUESTIONS AND HISTORY
ADDITIONAL PERSON 1

Relationship to you Title Male Female

First name Middle initials

Last name

Date of birth D D M M Y Y Y Y Country of nationality

Please answer each of these questions fully and accurately for the person named above. It is important to tell us about any known or suspected
medical conditions and symptoms, even if the applicant has not yet consulted a doctor about them. So you should include for example, any varicose
vein problems, ear, nose or throat problems and any pains, swellings or lumps. You should also include any symptoms/conditions for which remedies
are being taken, whether or not these are prescribed by a medical practitioner.
Please tick either Yes or No to each of these questions

1. Currently, is this person receiving treatment of any kind, eg receiving physiotherapy or taking medication?

2. Within the last six months, has this person experienced any signs or symptoms of any medical problem where you have not yet consulted a doctor/health professional?

3. Within the last four years, have you consulted a doctor/healthcare professional and/or been prescribed any drugs or medication?

4. Within the last four years, have you required assessment or treatment in a hospital or clinic, as a day case, emergency or in-patient?

5. Does this person have any medical devices or implants in your body eg heart pacemaker, artificial joint, or any internal fixation such as pins/plates or screws?

6. Does this person suffer from any chronic/long term medical or dental conditions or have any disability, abnormality, recurrent illness or injury?

7. Does this person require any consultations with a healthcare professional, tests, medication or treatment for any past or current medical problem?

This section applies if you have indicated ‘Yes’ to any medical questions. If you are unsure whether any details are relevant, you must include them.

Question What was the condition (or symptom When were symptoms first What was the treatment/ What was the outcome of the
number if not yet diagnosed)? experienced and when was medication (including dates and treatment (eg full recovery, ongoing
If applicable, state the area affected treatment completed (if names)? treatment required, likely to recur or
eg right leg. applicable)? awaiting test results)?

If you do not provide us with full details we may terminate your cover or it may stop us from paying your claims.

If there is insufficient space, please use a separate sheet and indicate that you have done so by ticking here:

Please tell us immediately if you or any additional people to be covered under the plan experience any symptoms before you
receive your membership documents. Failure to do so may mean we are unable to pay your claims.
6 MEDICAL QUESTIONS AND HISTORY
ADDITIONAL PERSON 2

Relationship to you Title Male Female

First name Middle initials

Last name

Date of birth D D M M Y Y Y Y Country of nationality

Please answer each of these questions fully and accurately for the person named above. It is important to tell us about any known or suspected
medical conditions and symptoms, even if the applicant has not yet consulted a doctor about them. So you should include for example, any varicose
vein problems, ear, nose or throat problems and any pains, swellings or lumps. You should also include any symptoms/conditions for which remedies
are being taken, whether or not these are prescribed by a medical practitioner.
Please tick either Yes or No to each of these questions

1. Currently, is this person receiving treatment of any kind, eg receiving physiotherapy or taking medication?

2. Within the last six months, has this person experienced any signs or symptoms of any medical problem where you have not yet consulted a doctor/health professional?

3. Within the last four years, have you consulted a doctor/healthcare professional and/or been prescribed any drugs or medication?

4. Within the last four years, have you required assessment or treatment in a hospital or clinic, as a day case, emergency or in-patient?

5. Does this person have any medical devices or implants in your body eg heart pacemaker, artificial joint, or any internal fixation such as pins/plates or screws?

6. Does this person suffer from any chronic/long term medical or dental conditions or have any disability, abnormality, recurrent illness or injury?

7. Does this person require any consultations with a healthcare professional, tests, medication or treatment for any past or current medical problem?

This section applies if you have indicated ‘Yes’ to any medical questions. If you are unsure whether any details are relevant, you must include them.

Question What was the condition (or symptom When were symptoms first What was the treatment/ What was the outcome of the
number if not yet diagnosed)? experienced and when was medication (including dates and treatment (eg full recovery, ongoing
If applicable, state the area affected treatment completed (if names)? treatment required, likely to recur or
eg right leg. applicable)? awaiting test results)?

If you do not provide us with full details we may terminate your cover or it may stop us from paying your claims.

If there is insufficient space, please use a separate sheet and indicate that you have done so by ticking here:

Please tell us immediately if you or any additional people to be covered under the plan experience any symptoms before you
receive your membership documents. Failure to do so may mean we are unable to pay your claims.
6 MEDICAL QUESTIONS AND HISTORY
ADDITIONAL PERSON 3

Relationship to you Title Male Female

First name Middle initials

Last name

Date of birth D D M M Y Y Y Y Country of nationality

Please answer each of these questions fully and accurately for the person named above. It is important to tell us about any known or suspected
medical conditions and symptoms, even if the applicant has not yet consulted a doctor about them. So you should include for example, any varicose
vein problems, ear, nose or throat problems and any pains, swellings or lumps. You should also include any symptoms/conditions for which remedies
are being taken, whether or not these are prescribed by a medical practitioner.
Please tick either Yes or No to each of these questions

1. Currently, is this person receiving treatment of any kind, eg receiving physiotherapy or taking medication?

2. Within the last six months, has this person experienced any signs or symptoms of any medical problem where you have not yet consulted a doctor/health professional?

3. Within the last four years, have you consulted a doctor/healthcare professional and/or been prescribed any drugs or medication?

4. Within the last four years, have you required assessment or treatment in a hospital or clinic, as a day case, emergency or in-patient?

5. Does this person have any medical devices or implants in your body eg heart pacemaker, artificial joint, or any internal fixation such as pins/plates or screws?

6. Does this person suffer from any chronic/long term medical or dental conditions or have any disability, abnormality, recurrent illness or injury?

7. Does this person require any consultations with a healthcare professional, tests, medication or treatment for any past or current medical problem?

This section applies if you have indicated ‘Yes’ to any medical questions. If you are unsure whether any details are relevant, you must include them.

Question What was the condition (or symptom When were symptoms first What was the treatment/ What was the outcome of the
number if not yet diagnosed)? experienced and when was medication (including dates and treatment (eg full recovery, ongoing
If applicable, state the area affected treatment completed (if names)? treatment required, likely to recur or
eg right leg. applicable)? awaiting test results)?

If you do not provide us with full details we may terminate your cover or it may stop us from paying your claims.

If there is insufficient space, please use a separate sheet and indicate that you have done so by ticking here:

Please tell us immediately if you or any additional people to be covered under the plan experience any symptoms before you
receive your membership documents. Failure to do so may mean we are unable to pay your claims.
6 MEDICAL QUESTIONS AND HISTORY
ADDITIONAL PERSON 4

Relationship to you Title Male Female

First name Middle initials

Last name

Date of birth D D M M Y Y Y Y Country of nationality

Please answer each of these questions fully and accurately for the person named above. It is important to tell us about any known or suspected
medical conditions and symptoms, even if the applicant has not yet consulted a doctor about them. So you should include for example, any varicose
vein problems, ear, nose or throat problems and any pains, swellings or lumps. You should also include any symptoms/conditions for which remedies
are being taken, whether or not these are prescribed by a medical practitioner.
Please tick either Yes or No to each of these questions

1. Currently, is this person receiving treatment of any kind, eg receiving physiotherapy or taking medication?

2. Within the last six months, has this person experienced any signs or symptoms of any medical problem where you have not yet consulted a doctor/health professional?

3. Within the last four years, have you consulted a doctor/healthcare professional and/or been prescribed any drugs or medication?

4. Within the last four years, have you required assessment or treatment in a hospital or clinic, as a day case, emergency or in-patient?

5. Does this person have any medical devices or implants in your body eg heart pacemaker, artificial joint, or any internal fixation such as pins/plates or screws?

6. Does this person suffer from any chronic/long term medical or dental conditions or have any disability, abnormality, recurrent illness or injury?

7. Does this person require any consultations with a healthcare professional, tests, medication or treatment for any past or current medical problem?

This section applies if you have indicated ‘Yes’ to any medical questions. If you are unsure whether any details are relevant, you must include them.

Question What was the condition (or symptom When were symptoms first What was the treatment/ What was the outcome of the
number if not yet diagnosed)? experienced and when was medication (including dates and treatment (eg full recovery, ongoing
If applicable, state the area affected treatment completed (if names)? treatment required, likely to recur or
eg right leg. applicable)? awaiting test results)?

If you do not provide us with full details we may terminate your cover or it may stop us from paying your claims.

If there is insufficient space, please use a separate sheet and indicate that you have done so by ticking here:

Please tell us immediately if you or any additional people to be covered under the plan experience any symptoms before you
receive your membership documents. Failure to do so may mean we are unable to pay your claims.
 7 YOUR APPLICATION DECLARATION

DATA PROTECTION NOTICE

Purpose: Telephone calls:
Personal data collected on you, and where appropriate, any additional people In the interest of continuously improving our service to members, your call may
specified in this application, will be used by Bupa Egypt and Bupa Global to be recorded and may be monitored.
process your claims, administer your plan and may be used to detect and prevent
fraud or improper claims. Research:
Anonymised or aggregated data may be used by Bupa Global, or disclosed to
Confidentiality: others, for research or statistical purposes.
The confidentiality of member and patient information is of paramount concern
to Bupa Egypt and Bupa Global. To this end, Bupa Global fully complies with Fraud:
UK Data Protection Legislation and medical confidentiality guidelines. Bupa Information may be disclosed to others with a view to preventing fraudulent or
sometimes uses third parties to process data on its behalf. In addition the rights improper claims.
of individuals under the UK Data Protection Act will be afforded to you, where Names and addresses:
applicable. Bupa Egypt and Bupa Global does not make the names and addresses of Bupa
Medical information: members or patients available to other organisations.
Medical information will be kept confidential. It will only be disclosed to those Keeping you informed:
involved with your treatment or care, including your general practitioner/ Bupa Global would, on occasion, like to keep you informed of Bupa Global
primary health physician, or to their agents, and, if applicable, to any person or products and services which it considers may be of interest to you.
organisation who may be responsible for meeting your treatment expenses, or
their agents. Claims information may also be shared with appointed third parties Contact address:
involved in the management and handling of your claim. Claims information may If you do not wish to receive information about Bupa Global’s products and
be discussed with either Bupa Egypt and Bupa Global agent/adviser where you services, or have any other Data Protection queries, please write to the Head
have requested the adviser to assist you. of Information Governance, at Bupa, 1 Angel Court, London EC2R 7HJ, or email
Member details: DataProtection@bupa.com.
All membership documents and confirmation of how we have dealt with any
claim you may make will be sent to you, as the main member.

Our complaints procedure:

It is Bupa Egypt and Bupa Global’s intention to provide a first class service to our members at all times. However, if you have any comments or complaints, you can call
the Bupa Global customer helpline on +44 (0) 1273 323 563, 24 hours a day, 365 days a year. Alternatively, you can email or write to the Head of Customer Relations via
www.bupa-intl.com/membersworld or Bupa Global, Victory House, Trafalgar Place, Brighton, BN1 4FY, UK. If we have not been able to resolve the problem and you wish
to take your complaint further, please write to our Head of Customer Relations at: Bupa Egypt Insurance, 55, Street 18, Maadi, Cairo, Egypt or you can call 16816 (from
inside Egypt), or +202 2768 1100.

DECLARATION
I hereby apply for the additional people I have added to my application to be included in my membership.
I declare that to the best of my knowledge and belief the information given in this application is true and complete.
I agree that the rules of the Bupa Egypt scheme will be binding on me and all eligible additional people included in my membership. I understand that I should read
the rules of the Bupa Egypt scheme carefully and ask Bupa Egypt for further information if I do not understand any point.
I agree that any cover which I may purchase for the USA shall terminate upon informing Bupa Global that I have become a resident of the USA.
I agree to contact Bupa Egypt if I, or any additional people to be covered under the plan, experience any symptoms before membership documents are received. I
understand that any subsequent claims may be affected if I do not.
I confirm that I give explicit consent on behalf of myself and any additional people specified in this application for Bupa Egypt to process our personal information
with respect to our membership, and I confirm that I have brought the Data Protection Notice to the attention of these additional people.

In view of the declaration above it is essential that complete information is supplied. We will not be able to process your
application if this form is incomplete. Please be sure to check the entire form.
Benefits may not be payable if you do not fully disclose any material facts which could influence our assessment and acceptance of this application and, if you are in
any doubt as to whether any facts are material, you should disclose them. You are advised to keep a record of all information you supply to us in connection with this
application, including letters. If you would like a copy of this application form, please ask us.
This product is insured by Bupa Egypt Insurance. Please be aware that this form must be received by Bupa Egypt no more than six weeks after the declaration date.
It is advisable that you fill in your form with complete up-to-date medical history before you sign and date this form. If we receive this form after six weeks from this
declaration date, or with incomplete information, we will be unable to register your details and enrol you on the plan.

Signature Date
EGY-COMP-APPF-EN-1711-V1.01-XXXX-0002168

For hearing or speech impaired members with a textphone, please call +44 (0) 1273 866 557.
We also offer a choice of Braille, large print or audio for our letters and literature. Please let us
know which you would prefer.