Your attention is drawn to the declaration at the foot of this form. it is important that all sections of this proposal form should be fully completed even if it is for renewal of or for an amount additional to an existing insurance. You should declare all conditions even though you have been declared fit. You should not omit to mention investigations where you have been told that the result is satisfactory. Failure to disclose material information may invalidate the policy.
All medical conditions must be stated giving all disabilities illnesses and accidents, with appropriate dates. if you have no medical history to declare state None:
(i) declined of deferred a Proposal from you?
(ii) charged or quoted more than standard rates?
(iii) cancelled or declined to renew your insurance
If Yes, give details:
Access to Medical Report Act, 1988 (please see below for further details)
I do/do not wish to see the report before it is sent to the Insurers*
*delete as applicable.
I have been informed of my rights under the Access to Medical Reports Act 1988 and I hereby consent to the Insurers obtaining medical reports in connection with this application.
I hereby declare that to the best of my knowledge and belief the answers to the foregoing questions whether in my own handwriting or not are true and complete and that I have not withheld any information which might influence the decision of the Insurers with regard to this proposal. I agree that this proposal and declaration shall be the basis of the Contract between me and the Insurers ifa policy is issued.
The Company reserves the right to impose special conditions or refuse to accept a proposal for insurance.
To process your application we may need to obtain a medical report from any doctor who has attended you. Y ou can withhold your consent for us to obtain the report, but without it cover may be restricted. Y ou are responsible for any fees incurred by us in obtaining such reports.
If you consent, you can see the medical report before it is sent to us. W e will inform you when we write to the doctor, and you need to obtain your copy within the next 21 days. If after 21 days the doctor has not heard from you, he can send his report directly to us, and you can still request a copy any time during the following six months for which you may be charged.
If you see the report within the 21 days, the doctor must obtain your consent before sending it to us. Y ou can ask the doctor to amend any part of the report which is incorrect or misleading. Y ou can attach a statement of your views on any part of the report where you and the doctor are not in agreement.
The doctor does not have to let you see any part of the report which could cause serious harın to your physical or mental health, or that of others, or would indicate the doctor's intentions towards you, or if information about you which has been supplied by another person, other than a health professional, would be revealed.
If the doctor withholds any part ofthe report from you, he must inform you ofthis fact. Ifit is the whole report which is affected, the doctor must not send it to us unless you consent to this.
If you do not wish to see the report, the doctor will send it to us immediately, but he must keep a record of the report for a peri od of six months, and you may apply to see a copy of the report during this time.
KVKK Metnini okudum ve tüm ayrıntılarıyla bilgilendirildim.