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

Please review and confirm declaration and authorisation before submission.

Personal Details of Applicant Edit

Membership no. of Bupa health insurance scheme

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)

Email address

Mobile Phone Number

Place of residence

Blua Health registration email address

CS Name

Type of referral

CS email

Customer name

Contract no

Mobile

Interested Product

Others (Please specific)

Preferred contact time

Enquiry details

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)

Confirmation

I confirm that I agree to register for Blua Health Pass Programme (the “Programme”). I confirm that the information that I have provided in this Registration is true and complete.

I confirm that I have read and agree to be bound by the terms and conditions of this Programme.

Personal Information Collection Statement

*Please tick to confirm

I have read and understood the Personal Information Collection Statement (“Statement”) of Blua (Asia) Services Limited (“BASL”) included in this registration form. I have also brought the Statement to the attention of the proposed Member and confirmed the understanding and agreement to it (if applicable).

I 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 have understood the Statement’s effect in respect of my/our personal information collected or held by BASL, including the use, storage, processing, transfer, disclosure 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 at https://www.bupa.com.hk/-/media/files/pdf/blua-health-pass.pdf; and

From time to time, BASL, our Group Companies (including our brand) and/or third party partners may wish to contact you with direct marketing communications by email, SMS, push notification, social media, instant messenger and/or other means that are available. Check this box if you consent to the use and transfer of your personal information for direct marketing purposes, as described in the Statement. You can change your preference at any time by using the response channels outlined in the Statement. If you do not agree, please do not check this box.

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