Bins 00542

Your application/
amendment form
Select Healthcare Plan
Underwritten
To be completed by the member
Please use this form to tell us about your medical history, and the medical history for anyone else you want to add to your
cover (a dependant).
We need this information to confirm your cover, process your claims and pay for any treatment you need that’s covered
by your policy.
J This form is for new members to complete by providing us accurate information and your medical history.
J If your group scheme has provided you with cover for any dependants (partner/children) please provide accurate
information and their medical history.
J If you are an existing member and are adding new dependants to your policy (with the authority of your scheme
administrator) please provide accurate information and their medical history.
J Give as much detail as you can and check all answers are correct to the best of your knowledge.
J If the answers are about a dependant (your partner and any child you or your partner are responsible for and who is
covered on your policy and named on your membership certificate), check with them to make sure the information
you’re providing is correct.
J Read the privacy notice on page 13 to see how we use your information. Please give a copy of this to any dependants
covered on your policy.
If you have any questions, please call us on 0345 600 1167 between 8am and 5pm Monday to Friday and we’ll be happy
to help.
We may record or monitor our calls.
Hearing or speech difficulties? Please use the Relay UK service on your smartphone or textphone.
Visit www.relayuk.bt.com for more information.
Sight difficulties? We offer documents in Braille, large print or audio. Please let us know if you’d like us to send you any.
Need to know
This policy is fully medically underwritten. This means that any symptoms or conditions you, or your dependant(s), had
before the policy started may not be covered.
We may ask you, or your dependant(s), for more medical information when you, or they, claim for up to five years after your
policy start date. This is to make sure that a claim doesn’t relate to something which isn’t covered by your policy.
If there’s reasonable evidence that you or a dependant didn’t take reasonable care answering our questions, your policy may
be cancelled, treated as if it never existed, or your claims may not be paid.
Application type
New application Addition of new dependants
Scheme details – please speak to your Group Secretary for these details
Company name
Bupa group number
Please tell us which products should be selected for this application.
Preferred cover start date D D M M Y Y Y Y

Need to know: we’ll try to start the cover (for the new application or change, whichever applies) on the above date.
We’ll confirm your start date on your membership certificate.
2
1. Your personal details
Title (please tick or list title if other) Mr Mrs Miss Ms Other
First name(s) Surname
Address
Postcode
Home telephone number Mobile telephone number
Email address
Date of birth D D M M Y Y Y Y Sex at birth Male Female
If you’re already a Bupa policyholder or beneficiary under a Trust

or have been in the past, please give us your membership or
registration number
If your group has provided you cover for any dependants (partner, children) please complete section 2.
2. Details of anyone else to be covered
Need to know
If your group hasn’t provided you cover for any dependants (partner, children), please go to section 3. If you would like
to add dependants please discuss this with your group administrator. Remember to check with each dependant that
you have their correct details and make sure that they’re shown our privacy notice on page 13 before sending us their
details. You must have their express agreement to send us this form on their behalf, or be their legal representative.
Need to know: adding people to your policy may impact the price you pay for your cover.
Person 2 Person 3 Person 4 Person 5
Title
First
name(s)
Surname
Relationship
to you
Date of D D M M D D M M D D M M D D M M
birth
Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y
Sex at birth Male Female Male Female Male Female Male Female
Need to add more people?
Please tick this box and use the notes on page 15. You’ll also need to answer sections 3 and 4 for them.
3
3. About you and anyone else to be covered
Need to know
Please answer each question for yourself and for each person named in section 2. If you’re an existing policyholder
and are only adding dependants, you don’t need to complete sections 3 and 4 about yourself, just about your
dependants.
Please tick ‘Yes’ or ‘No’ to every question as it applies to you and each dependant named in section 2. Remember to
check with them that you have their correct details and make sure they’re shown our privacy notice on page 13 before
sending us their details.
Main
policyholder
(Please tick the relevant box)
Are you a UK resident? Yes No Yes No Yes No Yes No Yes No

You are if you live in the UK
(including Isle of Man and
Channel Islands) for 183
days or more each year
Have you been registered Yes No Yes No Yes No Yes No Yes No

with a UK GP for at least six
months?
If not, do you have access to Yes No Yes No Yes No Yes No Yes No

your medical records in
English?
Need to know: You’ll need
to be registered with a GP in
the UK – if not, we may be
unable to offer you health
insurance cover
Are you a professional or Yes No Yes No Yes No Yes No Yes No

semi-professional
sportsperson?
By this we mean: are you
paid or sponsored to take
part in any sport?
If ‘Yes’, which sport(s)?

Please include the name of
the team, if applicable?
Need to know: When we
receive your application,
if we’re unable to offer you
health insurance cover,
we’ll let you know as soon
as we can
4
4. Medical history – part one
Need to know
This section asks for your previous and current health and medical details, and for each dependant named in section 2.
If you’re an existing member and are only adding your dependants, you don’t need to fill out the medical history
relating to your own health, only for your dependants. Please tick ‘Yes’ or‘ No’ to every question for each person.
Remember to check with them that you have their correct details and make sure they’re shown our privacy notice on
page 13 before sending us their details.
Please answer questions 1 to 5 to indicate if you or

anyone to be covered on your policy has:
J
seen a GP or other healthcare professional within the
last two years for any of the conditions or symptoms Main
listed Person 2 Person 3 Person 4 Person 5
policyholder
OR
J
been admitted to hospital, had an operation or any
investigations (for example scan, X-ray, blood test,
biopsy) within the last seven years for any of the
conditions or symptoms listed (Please tick the relevant box)
Question 1 – Musculoskeletal conditions Yes No Yes No Yes No Yes No Yes No
Have you had frequent or recurring pain, an operation in

the back, neck, joints or muscles, a bone or nerve
condition or any other condition that impacts normal
movement?
(For example: arthritis, cartilage/ligament problems,
sprains, joint replacement, gout, sciatica etc)
Question 2 – Cardiac conditions Yes No Yes No Yes No Yes No Yes No
Have you experienced shortness of breath, palpitations,

swollen ankles, angina, heart attack, stroke, mini-stroke/
TIA or any other related symptoms?
(For example: high blood pressure, high cholesterol, atrial
fibrillation, heart failure, heart disease, chest pains,
coronary artery disease etc)
Question 3 – Pelvic conditions Yes No Yes No Yes No Yes No Yes No
Have you had any problems with your bladder, bowels,

kidneys or prostate or do you have heavy or irregular
menstruation or have had a caesarean section?
(For example: urinary infections, irritable bowel,
incontinence, endometriosis, fibroids, pregnancy and/or
childbirth problems etc)
Question 4 – Sensory organ conditions Yes No Yes No Yes No Yes No Yes No
Have you had any problems with your vision, hearing,

balance or had an impacted tooth, wisdom tooth or
retained root?
(For example: cataracts, glaucoma, infections, abscess etc)
Question 5 – Mental health conditions Yes No Yes No Yes No Yes No Yes No
Have you talked with a GP, therapist, counsellor or any

other health professional about your mental health?
(For example: stress, depression, fatigue, anxiety, anorexia,
bulimia, compulsive disorders, schizophrenia etc)
5
4. Medical history – part one (continued)
Please also answer the following questions: Main

policyholder
(Please tick the relevant box)
Question 6 – Cancer conditions Yes No Yes No Yes No Yes No Yes No
Have you ever been diagnosed with or received treatment

for cancer, or had a test that indicates you may have
cancer?
(For example: tumours, abnormal smears, raised PSA
levels etc)
Question 7 – Any other ongoing conditions Yes No Yes No Yes No Yes No Yes No
Do you have any other health condition or symptoms for

which you need ongoing prescription medication, regular
medical tests, examinations or consultations?
Question 8 – Any planned treatment Yes No Yes No Yes No Yes No Yes No
Do you have any other health condition or symptoms

for which you intend to seek investigation or treatment in
the future or are currently receiving investigation or
treatment for?
If you’ve answered ‘Yes’ to any of the conditions here please give us full details on the following pages in
‘Medical history – part two’.
If you’ve answered ‘No’ to all of the above conditions, please go to section 5.
If you’d like to add any additional information, please tick this box and use the Notes on page 15.
6
4. Medical history – part two
Need to know
To help us fully understand your health and medical history, and the health and medical history of your dependants (if
applicable), please give more details on pages 8 to 11 about any of the conditions you answered ‘Yes’ to in part one.
Please give as much detail as possible. Without this information, your application for cover may be delayed. Below
are some examples to help you.
Definitions
Controlled: Condition or symptom ongoing but controlled by treatment or medication.
Recurrent: Occurring more than once, often or occasionally.
Likely to recur: Symptom free for a period of time, but likely to come back or happen again.
Fully recovered: Condition fully resolved or cured, with no symptoms and no medication.
Example one
Name: JOH N SMITH

JOHN S MITH
Question number from part one 2
Please describe the illness or medical problem H I G H CH OLE
OLESTER
STEROL
OL
Include which area of the body is affected, if
relevant (for example left, right, upper, lower)
When did symptoms start and end? Started D

0 1D 0M M
1 2Y 0Y 2Y Y2
If symptoms are ongoing please leave the end
Ended D D M M Y Y Y Y
date blank
Current state of the condition or symptom Ongoing Controlled  Recurrent

Likely to recur Fully recovered
Treatment prescribed or otherwise OV ER CO UN TER MEDI

MED I C A TI
TIOO N / DI
DIET /
P R E S CRI
CRIBB ED MEDI
MED I C A TI
TIOO N
How many times has this person seen a healthcare 2
professional about this symptom or condition in
the last two years?
If you’d like to declare another symptom or

condition for this question, please tick this box.
Example two
Name: JOH N SMITH

JOHN S MITH
Question number from part one 1
Please describe the illness or medical problem LEFT KNEE
K NEE PA
P A IN
When did symptoms start and end? Started D

0 5D 0M M
5 2Y 0Y 2Y Y1
Ended D
2 D0 M0 M
8 2Y 0Y Y2 Y
2
date blank
Current state of the condition or symptom Ongoing Controlled Recurrent

Likely to recur Fully recovered 
Treatment prescribed or otherwise P H YSIO
SIOTT H E R A P Y
How many times has this person seen a healthcare 5
the last two years?

7
4. Medical history – part two (continued)
Name:
Question number from part one
Please describe the illness or medical problem

When did symptoms start and end? Started D D M M Y Y Y Y

date blank

Treatment prescribed or otherwise
How many times has this person seen a healthcare

the last two years?

Name:


date blank


the last two years?

8
Name:


date blank


the last two years?

Name:


date blank


the last two years?

9
Name:


date blank


the last two years?

Name:


date blank


the last two years?

10
Name:


date blank


the last two years?

Name:


date blank


the last two years?

11
5. Medical reports – when we need more information from your doctor
We may need to ask your doctor for information about your consultation, tests, or treatment to see if your policy covers
these. We’ll need your permission to do this, and you have certain rights when it comes to your personal and medical
information:
J you can give your doctor permission to send us a medical report without you seeing it first or ask to see it before they
send it to us
J you can ask your doctor to show you the medical report before they send it to us so long as you do this within 21 days
from the date we ask them for it
J if you don’t contact your doctor within 21 days, we’ll ask them to send the report straight to us
J you can ask your doctor to change the report if you think it’s inaccurate or misleading - if they refuse, you can add your
own comments to it before they send it to us
J once you’ve seen the report, your doctor can’t send it to us unless you give them permission to do so
J you can ask your doctor not to send us the medical report - if this happens, we may be unable to tell you whether your
consultation, test or treatment is covered, and we may be unable to pay your claim
J you can ask your doctor to let you see a copy of your medical report within 6 months of it being sent to us
J your doctor can withhold some or all the information in the report if they believe the information:
• might cause you or someone else physical or mental harm, or
• would reveal someone else’s identity without their permission (unless the person is a healthcare professional, and the
information they provide is about your care)
J your doctor may charge you for a medical report - we’ll let you know if we’ll cover some of this cost - if not, you’ll need to
pay for it yourself.
There’s more detail about your rights in The Access to Medical Reports Act 1988 and The Access to Personal Files and Medical
Reports (NI) Order 1991.
6. Your legal declaration
Important: please read this declaration carefully before signing and dating the completed form.
1. To the best of my knowledge and belief the information given in this form is true, accurate and complete. I understand
that Bupa can end a person’s policy or refuse to pay a claim in full or part if there is reasonable evidence that I or a
dependant did not take reasonable care when providing any information requested in this form.
2. Where I have provided information on behalf of any other person to be covered on the policy, I confirm that I have
checked with them that the information is correct before completing this form and I have their express agreement to
submit this form on their behalf, or I am their legal representative.
3. I understand that my personal information and that of any other person to be covered on this policy will be processed by
Bupa for the purposes set out in Bupa’s privacy notice. I confirm that I have brought Bupa’s privacy notice to the attention
of the persons covered.
4. I agree to be bound by the terms of this policy (including in respect of those terms that apply to any other person to be
covered on this policy). I agree that English law will apply to the policy.
It is essential that you take reasonable care to provide us with full, complete and accurate information when you complete this
form. Please be sure to check the entire form.
If you do not provide complete information about yourself or any other person covered under the policy, we may have the
right to end your policy, or to refuse to pay all or part of a claim.
We recommend that you keep a record of all the information you supply to us in connection with this form, including letters.
If you would like a copy of this form, please ask us.
Obtaining medical reports from your doctor
J I understand that Bupa may need me to provide a medical report from my doctor to support my application, before
treatment is authorised or a claim paid.
J I understand that Bupa will gain verbal or written permission from me prior to any medical report being requested in this way.
J I have shown this declaration to the proposed dependants on the policy. I confirm that they understand that Bupa will gain
verbal or written permission from them prior to any medical report being requested in this way.
J I acknowledge the rights I have in relation to such reports as explained in section 5.
Signature
Date D D M M Y Y Y Y
12
Privacy notice – in brief
We are committed to protecting your privacy when dealing 6. Processing for profiling and automated decision-making
with your personal information. This privacy notice provides an Like many businesses, we sometimes use automation to provide
overview of the information we collect about you, how we use you with a quicker, better, more consistent and fair service, as well
it and how we protect it. It also provides information about your as with marketing information we think will interest you (including
rights. The information we process about you, and our reasons discounts on our products and services). This may involve
for processing it, depends on the products and services you use. evaluating information about you and, in limited cases, using
You can find more details in our full privacy notice available at technology to provide you with automatic responses or decisions.
bupa.co.uk/privacy. If you do not have access to the internet and You can read more about this in our full privacy notice. You have
would like a paper copy, please write to Bupa Data Protection, the right to object to direct marketing and profiling relating to
Willow House, 4 Pine Trees, Chertsey Lane, Staines-upon-Thames, direct marketing. You may also have rights to object to other
Middlesex TW18 3DZ. If you have any questions about types of profiling and automated decision-making.
how we handle your information, please contact us at 7. Sharing your information
dataprotection@bupa.com We share your information within the Bupa group of companies,
Information about us with relevant policyholders (including your employer if you are
In this privacy notice, references to ‘we’, ‘us’ or ‘our’ are to Bupa. covered under a group scheme), with funders who arrange
Bupa is registered with the Information Commissioner’s Office, services on your behalf, those acting on your behalf (for example,
registration number Z6831692. Bupa is made up of a number brokers and other intermediaries) and with others who help us
of trading companies, many of which also have their own provide services to you (for example, health-care providers) or
data-protection registrations. For company contact details, who we need information from to handle or check claims or
visit bupa.co.uk/legal-notices entitlements (for example, professional associations). We also
1. Scope of our privacy notice share your information in line with the law. You can read more
This privacy notice applies to anyone who interacts with us about about what information may be shared in what circumstances
our products and services (‘you’, ‘your’), in any way (for example, in our full privacy notice.
email, website, phone, app and so on). 8. International transfers
2. How we collect personal information We work with companies that we partner with, or that provide
We collect personal information from you and from certain other services to us (such as health-care providers, other Bupa
organisations (those acting on your behalf, for example, brokers, companies and IT providers) that are located in, or run their
health-care providers and so on). If you give us information about services from, countries across the world. As a result, we transfer
other people, you must make sure that they have seen a copy your personal information to different countries including transfers
of this privacy notice and are comfortable with you giving us from within the UK to outside the UK, and from within the EEA
their information. (the EU member states plus Norway, Liechtenstein and Iceland)
to outside the EEA, for the purposes set out in this privacy notice.
3. Categories of personal information We take steps to make sure that when we transfer your personal
We process the following categories of personal information information to another country, appropriate protection is in place,
about you and, if it applies, your dependants. This is standard in line with global data-protection laws.
personal information (for example, information we use to contact
you, identify you or manage our relationship with you), special 9. How long we keep your personal information
categories of information (for example, health information, We keep your personal information in line with periods we work
information about race, ethnic origin and religion that allows out using the criteria shown in the full privacy notice available
us to tailor your care), and information about any criminal on our website.
convictions and offences (we may get this information when 10. Your rights
carrying out anti-fraud or anti-money-laundering checks, or You have rights to have access to your information and to ask
other background screening activity). us to correct, erase and restrict use of your information. You also
4. Purposes and legal grounds for processing have rights to object to your information being used; to ask us to
personal information transfer information you have made available to us; to withdraw
We process your personal information for the purposes set out in your permission for us to use your information; and to ask us
our full privacy notice, including to deal with our relationship with not to make automated decisions which produce legal effects
you (including for claims and handling complaints), for research concerning you or significantly affect you. Please contact us
and analysis, to monitor our expectations of performance if you would like to exercise any of your rights.
(including of health providers relevant to you) and to protect 11. Data-protection contacts
our rights, property, or safety, or that of our customers, or others. If you have any questions, comments, complaints or suggestions
The legal reason we process personal information depends on about this notice, or any other concerns about the way in
what category of personal information we process. We normally which we process information about you, please contact us at
process standard personal information on the basis that it is dataprotection@bupa.com. You can also use this address to
necessary so we can perform a contract, for our or others’ contact our Data Protection Officer.
legitimate interests or it is needed or allowed by law. We process
You also have a right to make a complaint to your local privacy
special categories of information because it is necessary for
supervisory authority. Our main office is in the UK, where the local
an insurance purpose, because we have your permission or as
supervisory authority is the Information Commissioner, who can be
described in our full privacy notice. We may process information
contacted at: Information Commissioner’s Office, Wycliffe House,
about your criminal convictions and offences (if any) if this
Water Lane, Wilmslow, Cheshire SK9 5AF, United Kingdom.
is necessary to prevent or detect a crime.
5. Marketing and preferences Phone: 0303 123 1113 (local rate).
We may use your personal information to send you marketing by
post, phone, social media, email and text. We only use your personal
information to send you marketing if we have either your permission
or a legitimate interest. If you don’t want to receive personalised
marketing about similar products and services that we think are
relevant to you, please contact us at optmeout@bupa.com or
write to Bupa Data Protection, Willow House, 4 Pine Trees,
Chertsey Lane, Staines-upon-Thames, Middlesex TW18 3DZ
13
Notes
14
Bupa health insurance is provided by:
Bupa Insurance Limited. Registered in England and Wales with
registration number 3956433.
Bupa Insurance Limited is authorised by the Prudential Regulation
Authority and regulated by the Financial Conduct Authority and the
Prudential Regulation Authority.
Arranged and administered by:
Bupa Insurance Services Limited, which is authorised and regulated by
the Financial Conduct Authority. Registered in England and Wales with
registration number 3829851.
Registered office: 1 Angel Court, London EC2R 7HJ
© Bupa 2023
bupa.co.uk
SEL/3823/JUN23 BINS 00542

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Your application/

New application Addition of new dependants

Bupa group number

Please tell us which products should be selected for this application.

Preferred cover start date D D M M Y Y Y Y

Title (please tick or list title if other) Mr Mrs Miss Ms Other

First name(s) Surname

Home telephone number Mobile telephone number

Date of birth D D M M Y Y Y Y Sex at birth Male Female

If you’re already a Bupa policyholder or beneficiary under a Trust

2. Details of anyone else to be covered

Person 2 Person 3 Person 4 Person 5

Need to add more people?

(Please tick the relevant box)

Are you a UK resident? Yes No Yes No Yes No Yes No Yes No

Have you been registered Yes No Yes No Yes No Yes No Yes No

If not, do you have access to Yes No Yes No Yes No Yes No Yes No

Are you a professional or Yes No Yes No Yes No Yes No Yes No

If ‘Yes’, which sport(s)?

Please answer questions 1 to 5 to indicate if you or

Question 1 – Musculoskeletal conditions Yes No Yes No Yes No Yes No Yes No

Have you had frequent or recurring pain, an operation in

Question 2 – Cardiac conditions Yes No Yes No Yes No Yes No Yes No

Have you experienced shortness of breath, palpitations,

Question 3 – Pelvic conditions Yes No Yes No Yes No Yes No Yes No

Have you had any problems with your bladder, bowels,

Question 4 – Sensory organ conditions Yes No Yes No Yes No Yes No Yes No

Have you had any problems with your vision, hearing,

Question 5 – Mental health conditions Yes No Yes No Yes No Yes No Yes No

Have you talked with a GP, therapist, counsellor or any

Please also answer the following questions: Main

(Please tick the relevant box)

Question 6 – Cancer conditions Yes No Yes No Yes No Yes No Yes No

Have you ever been diagnosed with or received treatment

Do you have any other health condition or symptoms for

Question 8 – Any planned treatment Yes No Yes No Yes No Yes No Yes No

Do you have any other health condition or symptoms

Name: JOH N SMITH

When did symptoms start and end? Started D

Current state of the condition or symptom Ongoing Controlled  Recurrent

Treatment prescribed or otherwise OV ER CO UN TER MEDI

If you’d like to declare another symptom or

Name: JOH N SMITH

When did symptoms start and end? Started D

Current state of the condition or symptom Ongoing Controlled Recurrent

If you’d like to declare another symptom or

Question number from part one

Please describe the illness or medical problem

When did symptoms start and end? Started D D M M Y Y Y Y

Current state of the condition or symptom Ongoing Controlled Recurrent

Treatment prescribed or otherwise

How many times has this person seen a healthcare

If you’d like to declare another symptom or

Question number from part one

Please describe the illness or medical problem

When did symptoms start and end? Started D D M M Y Y Y Y

Current state of the condition or symptom Ongoing Controlled Recurrent

Treatment prescribed or otherwise

How many times has this person seen a healthcare