H o w to s u b mit a H ealth I ns u r ance A pplicati o n In order to expedite the processing of your application, please make sure to complete the following steps. C o m p l e t e H e a lt h I n s u r a n c e A p p l ic at i o n •Indicate deductible plan, mode of payment, physical address, and date of signature. •Dependents 19-24 years old must be full-time students and attach proof of enrollment, providing the name of the institution. •Please answer all questions and provide an explanation where applicable. •To expedite processing, be very specific as to for whom, when, where, and how a specific condition has been diagnosed and treated (under Medical Information section). •Please read the Acknowledgement and Authorizations section and make sure to indicate “Yes” or “No”. As indicated there, selecting “No” will result in the rejection of the application for enrollment. T r e at i n g Ph y s ici a n S tat e m e n t All applicants 65 years of age or older must submit a Treating Physician Statement completed by their doctor and provide the most current results of the following exams: •Chest X-ray (valid up to 12 months) •Electrocardiogram EKG (valid up to 12 months) •Lab work (valid up to 6 months) •Pap Smear (valid up to 12 months) •Mammogram results (valid up to 12 months) Questionnaires Additional coverage •When requesting a rider for maternity and perinatal complications, a Maternity Questionnaire is required and must be completed by the applicant. •When requesting a transplant procedures rider at renewal time, an Application for Transplant Procedures Rider signed by the policyholder is required. Medical Conditions If the insured declares any of the following conditions, his/her treating physician should complete the corresponding questionnaire as specified below. Conditions Questionnaire Asthma, emphysema Asthma and Respiratory Disorders Diabetes or hyperglycemia Diabetes and Other Glucose Metabolism Disorders Gastritis, hiatal hernia, acid reflux GERD (gastroesophageal reflux disorder) Gastrointestinal Disorders Hypertension, arrhythmia, or other cardiac conditions Heart Disease and Hypertension Epilepsy or convulsions Seizures Anxiety, depression, attention deficit disorder Psychiatric Disorders H o w to s u b mit a H ealth I ns u r ance A pplicati o n Wa i v e r o f Wa i t i n g P e r i o d Bupa may waive the 60-day waiting period (except for Critical Care). Please submit the following documents with the Health Insurance Application: •Proof of previous coverage. •Certificate of coverage for the last 12 months (provide with application). •Last payment receipt (provide with application). •Complete section 3: Other Insurance Information. R e v i e w o f E x c l u s i o n s o r Li m i tat i o n s If the policy is approved with some type of exclusion or limitation, it may be reevaluated on the policy’s second anniversary. For this revision, please submit an Application to Request Review of Exclusions and/or Limitations completed by the policyholder and any updated medical information related to the exclusion or limitation. S e r v ic e s •Real Time Underwriting (RTU) - You may reach our staff at any point during the application process. •Direct calls to policyholders in order to explain the underwriting process. •Direct calls to treating physician for additional information related to the declared condition(s). C o n ta c t U s For further assistance, please email us at [email protected] or call an RTU representative at one of the following numbers: Argentina 0 800 222 0270 Bahamas 800 393 9416 Mexico Peru Brazil 0 800 892 1652 Uruguay Chile 1 230 020 5466 U.S. Virgin Islands Dominican Republic Ecuador 800 417 1746 02 396 5656 / 57 Venezuela Other Countries 800 426 3339 0 800 77 987 000 411 005 2684 866 872 1092 0 800 102 9560 305 271 4788 N E W BU S I N E S S A P P L I C AT I O N CHECKLIST Exclusive Care • Privilege Care • Advantage Care • Secure Care • Essential Care • Critical Care BEFORE YOU SUBMIT AN INDIVIDUAL HEALTH INSURANCE APPLICATION FOR NEW BUSINESS, PLEASE MAKE SURE YOU HAVE INCLUDED ALL THE NECESSARY INFORMATION: 1. PERSONAL INFORMATION 5. BENEFICIARY INFORMATION oFill out all the boxes with name, date of birth, height, and weight for each applicant. oPlease make sure you complete the section with the beneficiary information. o Make sure the information is legible. 6. MEDICAL INFORMATION oIf the application includes full-time students ages 19 to 24, provide a certificate or affidavit from the college or university as evidence of full-time student status. o If the application includes a person age 65 or older, please also complete Treating Physician Statement with all the required medical information. 2.PRODUCT, PLAN AND COVERAGE REQUESTED ADDITIONAL o Make sure you select a product and deductible plan, as well as any additional coverage needed. If no additional coverage is selected, none will be granted. o If requesting additional coverage for complications of maternity, please also complete a Maternity Questionnaire. o If requesting additional coverage for transplant procedures, please also complete an Application for Transplant Procedures Rider. 3. OTHER INSURANCE INFORMATION oIf applicant has health insurance with another company, please make sure you complete all the necessary information and attach a copy of the certificate of coverage, as well as receipt of last payment. 4. GENERAL INFORMATION oPlease make sure you provide a complete address, telephone, fax, and email information. oPlease make sure you complete this section with information regarding family doctors, medical check-ups, medical conditions, medications, habits, and family history for all applicants. Questions answered with “Yes” need to be explained in section (6.4). 7. ACKNOWLEDGEMENT AND AUTHORIZATIONS oPlease read this section carefully and select “Yes” or “No” for both the “Authorization to collect information” and the “Authorization to disclose health information”. As indicated in this section, selecting “No” will result in the rejection of the application for enrollment. 8. SIGNATURES oMake sure both Policyholder and Spouse (if applying for coverage) sign and date the application. 9. PAPERLESS CUSTOMER SIGN UP oSelect this option to sign up as a paperless customer and receive all insurance documents online. 10. PAYMENT INFORMATION oComplete all the information required in this section and select a payment method. o Payment must be submitted together with the application. oSelect “Yes” for Bupa to automatically debit the account for future renewals, and sign and date this section too. THE APPLICATION IS VALID FOR 90 DAYS AS OF THE DATE OF SIGNATURE. Bupa Insurance Company 7001 S.W. 97th Avenue, Miami, Florida 33173 Tel. +1 (305) 398 7400 • Fax +1 (305) 275 8484 • www.bupalatinamerica.com • [email protected]