Preview Complimentary Bupa Hospital Cash Coverage (Plan 3) Application Form

Please review and confirm declaration and authorisation before submission.

Personal Details of Applicant Edit

Membership No. of Bupa health insurance scheme (If applicable)

Title

Gender

Surname in English (same as Hong Kong ID card)

Given name in English (same as Hong Kong ID card)

HKID Card No.

Date of Birth (DD/MM/YYYY)

Hong Kong Correspondence Address (English)

E-mail address

Mobile Phone Number

Place of residence

Bank Account for Claims PaymentEdit

Personal Hong Kong savings / current account number

Bank No. & Bank Name

Account No.

Account Holder’s Name

Hong Kong identity card number (including the number in brackets)

Declaration and Authorisation

I, on behalf of myself / the proposed Member as listed in this Application, apply as a Member of Complimentary Bupa Hospital Cash Coverage (“Coverage”). I declare that, to the best of my knowledge and belief, the statements contained in this Application are true and complete.

I agree to be bound by the terms and conditions of the Provisions of this Coverage, which I understand are available on request and will be provided to me if this application is approved.

Personal Information Collection Statement

*Please tick to confirm

Click here to view the Personal Information Collection Statement

I have read and understood the Personal Information Collection Statement (“Statement”) included in this application form. I have also brought the Statement to the attention of the proposed Member (or the guardian if applicable) and confirmed the understanding and agreement to it.

I / the proposed Member consent to the transfer of my/our personal data within or outside of Hong Kong for the purposes and to the types of transferees as set out in the Statement. I / the proposed Member have understood the Statement’s effect in respect of my/our personal information collected or held by Bupa (Asia) Limited, including the use, storage, processing, transfer, disclosure and/ or sharing of part of or all of my/our personal information within the Group Companies in accordance with the Statement. The updated version of Statement is available for download from www.bupa.com.hk or our App; and

By ticking this box, I consent to Bupa using my personal data, including my name, contact details, gender, health and family status, to send me marketing communications (including by email, SMS or instant messenger ) as described in the Personal Information Collection Statement, including in relation to insurance (such as subscription discounts), wellness, rewards, loyalty or privileges programmes and related products and services. I understand that I have the right to request Bupa to cease using my personal data for direct marketing purposes by emailing customercare@bupa.com.hk or calling the Bupa Customer Care helpdesk on 2517 5333. If I do not agree, please do not tick this box.

Declaration of residency

*Please tick to confirm

By ticking this box, I acknowledge that Bupa may terminate the cover for the proposed Member with immediate effect if the law of the country in which the proposed Member is located, or the proposed Member’s Place of Residence or nationality, including but not limited to USA and Japan, or any other law which applies to Bupa or the Contract, prohibits the provision of healthcare cover by Bupa to local nationals, residents or citizens. I further declare that the proposed Member is not US permanent residents. I understand that I am obliged to immediately notify Bupa in writing if the proposed Member becomes a permanent resident of USA during the Contract year. For the above purpose, ‘permanent resident’ shall mean a person residing in a country who is a citizen of or who is permitted under applicable laws to live and work, on a permanent basis, in that country.

I understand that no cover will be payable under the Coverage unless this Application is approved by Bupa (Asia) Limited (“Bupa”).

Edit