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Private Health - New Member Application

Section A - Member Details
Level of Cover
Please select the level of cover required:
Family Member Details - Partner
Family Member Details - Dependent 1
Family Member Details - Dependent 2
Family Member Details - Dependent 3
Family Member Details - Dependent 4
Family Member Details - Dependent 5
Section B - Healthcare Scheme Choices
(Your membership will commence as of this date)

Second C - Membership Joining Criteria
Your membership will be based on Full Medical Declaration. Please complete the following medical questions. It is important that questions are answered honestly and in full as failure to do so could lead to us not paying a future claim or may lead to a membership being declared void. Where there are pre-existing conditions, we require you to provide details of the condition, including history, any treatment provided, medication taken and any future planned medical events.
Medical Questionnaire
Has any applicant experienced symptoms or, and/or received treatment, medical or advice for any form of:
If you answered “Yes” to any of the above, please provide more information below:
Height and Weight
Please indicate the height and weight of applicants
Policy Terms and Conditions
• The membership will not commence until we have accepted your application. • If you have a birthday while your application is being processed, the terms may differ from those originally quoted. • We may offer you revised membership terms but, in some circumstances, we may not be able to offer you membership. • H3, our business associates and service providers will use your information for administration, customer services and fraud prevention. We will pass your information to them for these purposes. • We may need to get medical reports to support your application. Before we ask any doctor that you have consulted to complete a report, we need your permission under the Access to Medical Reports Act 1988. We may ask you to contact your doctor if we are experiencing delays in receiving reports which we have asked for. • We will pass your information on to any legal or regulatory body, if required to do so.
• I understand that my application is subject to written acceptance from H3. • I accept the terms, conditions and limits of the Health Scheme that I have applied for. • I acknowledge that H3 reserves the right to cancel this membership if any amount due is not paid by the Direct Debit due date. • I confirm that I have answered all questions truthfully and that all information provided is to the best of my knowledge and correct. • I have read and understood the terms and conditions of this membership. • I have read and understood the joining criteria for this scheme. • I will advise you immediately if there are any changes in the information given on this form which occur between the date of signing and the start date of the membership provided under this membership. • I understand that if H3 need to investigate or establish material facts, this may delay the claims process. • I understand it is my responsibility to read and understand the benefit guidelines and direct debit guarantee for this plan. • I confirm that any information I have given in this application about another person is done so with their permission as they have appointed me to act on their behalf. This includes providing consent for H3 to hold and process their personal data. • I confirm that no information has been withheld that could change the terms of my application. • I understand that failure to disclose all relevant information relating to this application may result in a claim not being paid and, in some cases, the contract being declared void.