Trafalgar  
International Ltd

Health and Hospitalisation Insurance
Application Form

Please read through the following before completing this application and complete in block capitals.

All information supplied will be treated in strict confidence.  All material facts relating to these questions must be disclosed.  Failure to do so may invalidate the policy.  A material fact is one which is likely to influence an Insurer in the assessment and acceptance of this application.  If you are in any doubt as to whether a fact is material then it should be disclosed.  As proposer you should answer all questions and sign the declaration on behalf of all persons to be insured.  A copy of this application will be supplied to you by the Insurers on request within three months of completion.  You should keep a record (including copies of all letters) of all information supplied to us for the purpose of entering into this contract.

The 'proposer' is applying to be the policyholder and is responsible for paying the premium.

Details of the Proposer	
Surname:			
Title: Mr/Mrs/Miss/Ms/Other		
Forename:		
Other Initials:		
Sex:	Male		Female		
Residential Address:

		
Correspondence Address:

		
Telephone number	Home:		Business:		
Fax number:		
e-mail address		
Date of birth:		
Nationality:		
Country of which you are a passport holder:		
Occupation:		
Industry:		
Dependents to be included in this plan 
If there is insufficient space for inclusion of all dependants, please provide details on the reverse of this form as shown.	
	Dependant l	Dependant 2	Dependant 3	
Surname				
Forename				
Other initials				
Sex M/F				
Relationship to policyholder				
Date of birth (dd/mm/yy)				
Occupation				
Nationality				
	Dependant 4	Dependant 5	Dependant 6	
Surname				
Forename				
Other initials				
Sex M/F				
Relationship to policyholder				
Date of birth (dd/mm/yy)				
Occupation				
Nationality				
Commencement Date	
The inception date of this policy will be the date on which this application is received and accepted by the Insurers.  However, if you require an inception date in the future you may do so by completing the commencement date below.  Under no circumstances will policies be backdated.	
Commencement Date (dd/mm/yy)		
Optional Modules	
This Plan enables you to choose various Optional Modules as amendments to the Foundation Module in order to suit you personal requirements.  Please clearly tick the Optional Modules which you have selected.  Your policy will be issued on this basis If no boxes are ticked in this section, it will be assumed that cover is required as per the Foundation Module.	
Optional Module 001:	Chronic Conditions	Yes		No		
Optional Module 002:	Routine Dental Treatment	Yes		No		
Optional Module 003:	Major Restorative Dental Work	Yes		No		
Optional Module 004:	Normal Pregnancy & Childbirth	Yes		No		
Optional Module 005:	Evacuation/Repatriation Extension	Yes		No		
Optional Module 006:	Policy Excess (tick box) 
(The Foundation Module carries a US$ 100 Policy Excess as standard.  If none of the options below are ticked this will automatically apply.)	Nil		500		
	US$50		US$1,000		
	US$200		US$2,000		
	US$300		US$5,000		
Optional Module 007:	In-Patient Only cover	Yes		No		
Optional Module 008:	USA Elective Treatment	Yes		No		
Premium Payment	
Tick the payment method you require and complete all details relevant to that method.  All premiums must be paid annually.	
Cheque Payment: 
All cheques must be payable to "Trafalgar International Limited".  Please ensure that the name of the Policyholder (as declared in Section 1 of this form) is clearly stated on the reverse of the cheque.		
Bank Transfer: 
Please ensure that the name of the Policyholder (as declared in Section 1 of this form) is clearly stated on any Bank Transfer.  We cannot accept liability for any bank transfer that does not clearly identify the Policyholder.		
Our Bank details for Bank transfers are: 		
Credit Card: 
For payment by credit card please note that your premium will be collected upon receipt of this application which may be in advance of the commencement date.  Future premiums will be collected 7 days in advance of the renewal date.  Exchange rate differences may apply to the premium collections	
American Express		Visa		Mastercard		
Card Number		
Expiry Date		
Cardholder’s Name		
Cardholder’s Statement Address		
Cardholder’s Authorisation Signature		
Pre-Existing Conditions	
Benefits will not be available for any medical condition or related condition for which you have received medical treatment, had symptoms of or sought advice prior to your Date of Entry, until two consecutive years have elapsed, after the Date of Entry, during which no Treatment or Advice was given in respect of that medical condition or any related medical condition.	
Declarations	
I understand and accept section 6 on Pre-Existing Conditions.	
I have read and understand the full Terms and Conditions of this Policy.	
I declare that to the best of my knowledge and belief the information given in this application is true and complete.  I agree to accept and conform to the terms of the policy when issued, unless I cancel this policy within 3o days from the commencement date.	
I confirm that I have checked and found correct any answers or statements in this application that are not in my own handwriting.	
I confirm that I have selected a US$ Plan.  In the event that I wish to transfer to the £ Sterling Plan at a future Renewal Date, I accept that this is acceptable to Underwriters' authorisation and that this may incur an additional charge.	
Proposer's signature:		
Date (must be completed): (dd/mm/yy)		

There is no obligation to calculate your premiums, however, if you wish to do so, then the formula below may be of assistance.  Please contact Trafalgar International Limited if you would like us to calculate your premium.

The premiums calculated by Trafalgar will be deemed to be correct.

Please note that all persons to be covered under this Policy must select the same level of cover.

Benefit	
Notes	
Assistance Notes		Example Age 3o, Area 2, US$ 500
Excess, Chronic	
FOUNDATION MODULE 
Premium		(a)		(a) US$ 957.00	
OPTIONAL MODULES					
In-Patient Only	Less 30 %	(b)	(a-30%)		(b)	
Policy Excess 
US$	Plus	% 
Less	%	(c)	(b+/-     %)		(c) US$ 794.31(-17%)	
Chronic		(d)	(c) + US$ value		(d) US$ 1049.31 (US$ 255)	
Dental: 	Routine
		Restorative
		Combined	Only one
selection	(e)	(d) + US$ value		(e)	
Normal Pregnancy & Childbirth	This premium applies per policy not per person	(f)	(e) + US$ value		(f)	
Evacuation/Repatriation Extension		(g)	(f) + US$ value		(g) US$ 1134.31 (US$ 85)	
Total		(h)	(g)		(h) US$ 1134.31	
Insurance Premium Tax	Applicable in various European Countries	(i)	(h) +      %		(i)	
ANNUAL PREMIUM including I.P.T.				(j) US$ 1134.31	

Please return completed application form to:
Trafalgar International Limited
21st Fl. Vongvanij Complex, Building B,
100/63 Rama 9 Road, Huay Kwang,
Bangkok 10320, Thailand
Tel.: (66) 0-2645-1170; Fax: (66) 0-2645-1180
E-mail: insure@trafalgar-intl.com