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Application form for Complimentary Bupa Hospital Cash Coverage (Plan 3)

Please complete this form in ENGLISH and BLOCK LETTERS.

If you submit your application on or before 5 working days prior to the end of the month, your cover will take effect on the first day of the following month. 12-month coverage start from the Coverage Effective Date and will be automatically ended at the Coverage End Date.

Applicant information (applicants must be 18-64 years old)

Cover: Complimentary Bupa Hospital Cash Coverage – Plan 3: HK$500 each day

Membership no. of Bupa health insurance scheme

Title *

Gender *

Male

Female

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) *

*PO boxes, hotel addresses and overseas addresses are not accepted

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

Preferred contact time

Enquiry details *

Bank Account for Claims Payment

Claims payment will be settled by autopay only. All claims payment will be paid to the Subscriber only. I hereby agree and authorise Bupa (Asia) Limited to settle claims payment to the account below.
Rest assured that the account information provided is solely used for claims payment.

Personal Hong Kong Savings / Current Bank Account Number (HK$ only)

Bank No. & Bank Name

Account No.

Account Holder’s Name

*Same as bank statement or passbook

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

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Complimentary one year hospital cash coverage

Complimentary Bupa Hospital Cash Coverage (Plan 3)

Please complete this form in ENGLISH and BLOCK LETTERS.

If you submit your application on or before 5 working days prior to the end of the month, your cover will take effect on the first day of the following month. 12-month coverage start from the Coverage Effective Date and will be automatically ended at the Coverage End Date.