Apply Now | Healthcare for Nomad

Insurance Application Form

Main Insurer Details

First Name

Last Name

Phone Number (Incl Country Code)

Home Address

Country of Residence

Nationality

Gender

Date of Birth required

Insurer 2 Details

First Name

Last Name

Phone Number (Incl Country Code)

Home Address

Country of Residence

Nationality

Gender

Date of Birth required

Insurer 3 Details

First Name

Last Name

Phone Number

Home Address

Country of Residence

Nationality

Gender

Date of Birth required

Insurer 4 Details

First Name

Last Name

Phone Number

Home Address

Country of Residence

Nationality

Gender

Date of Birth required

Insurer 5 Details

First Name

Last Name

Phone Number

Home Address

Country of Residence

Nationality

Gender

Date of Birth required

Insurer 6 Details

First Name

Last Name

Phone Number

Home Address

Country of Residence

Nationality

Gender

Date of Birth required

Insurer 7 Details

First Name

Last Name

Phone Number

Home Address

Country of Residence

Nationality

Gender

Date of Birth required

Coverage Selection

Expiry

CVC

Declaration

Healthcare For Nomads only collects personal data that it believes is relevant in connection with your Healthcare For Nomads cover.
Failure to supply personal data requested on this form may result in Healthcare For Nomads being unable to provide or continue to
provide client management services and/or related services or products which Healthcare For Nomads may from time to time offer
or provide, or to comply with applicable laws or guidelines issued by applicable regulatory authorities.
For the purposes of administering your Healthcare For Nomads cover and our business relationship with you, Healthcare For Nomads
shares your personal data with its employees, auditors, contractors and consultants and other parties, including its parent
and affiliated companies who require such information for those purposes. These include third parties that provide services
to us or on our behalf and third parties that collaborate with Healthcare For Nomads in the provision of services to you.
If you wish to update, access or correct your personal data collected by Healthcare For Nomads, or otherwise have questions
about Healthcare For Nomads data protection policies and procedures, you may make such request at any time, with your name
and contact number to our Chief Compliance Officer.

I/We declare that all information provided in this application form, including this declaration and any supporting documentation
are complete and true to the best of my/our knowledge and belief.
I/We understand that I/We have the right to cancel and obtain a refund of any premium under the terms of the “Cooling-Off”
period.
I/We understand that in the event of any doubt about the content of any documents provided by Healthcare For Nomads or
the terms of any insurance provided by Healthcare For Nomads I/We should obtain independent professional advice prior to the
completion of this application form.

First name

Last Name

Date required

Card Number

We want you to be covered as soon as possible, so your payment will be processed as soon as possible and your policy activated. However, if after reading the full terms and conditions and exclusions of your policy, you feel that the cover is not right for you, you can cancel your policy and receive a full refund under the terms of the 14-day cooling off period.

Coverage Plan

Major Medical

Standard

Comprehensive

Fully Comprehensive

Please select how you want to pay

Visa

Mastercard