Emergency Health Insurance Form printable pdf download

EMERGENCY

HEALTH INSURANCE

This form can be emailed or submitted to us direct together with the required documents.

Address and telephone details DEFINITLY be provided for EMERGENCY.

Please fill this form with CAPITAL LETTERS by using a pen.

All sections of this form must be completed in Full. Failure to do so will result in delay or denial of

benefits.

Personal details

Title:

Mrs

Miss

First Name:

Student No.

Surname:

Gender:

Female

Male

Date of

Birth:

Nationality:

Passport No.

Phone No.

E-mail:

Address:

HEALTH DECLARATION NOTICE AND AUTHORISATION

1. I agree, declare and undertake that the information given by me on this application form and attached documents about myself to be insured is

complete and accurate, that ı have not concealed anything which NORTHPRİME İNSURANCE LTD.

2. I declare that I hereby authorize NORTHPRİME İNSURANCE LTD. to obtain information from any physician, healthcare institution and other insurance

companies on matters concerning the scope of my health insurance and to give information to Sağlık Sigortaları Bilgi ve Gözetim Merkezi (SAGMER)

[Health Insurance Information and Supervision Centre] on matters concerning the scope of my health insurance.

3. If the policy is issued and if, after having read the special and general conditions of the policy, ı don't send any objection of me about the policy to

NORTHPRİME İNSURANCE LTD. before making a claim under the policy and case at latest within 30 days following the inception date of the policy, ı

declare that ı have agreed all Special and General Conditions of the policy.

4. I have read, understood and agreed the information and Enlightenment Form which is an integral part of this

a pplication form .

5. I accept any notice required to be sent by NORTHPRİME İNSURANCE LTD. can be sent by mobile phone

message or e-mail.

6. I agree and declare that receipt of this application form by NORTHPRİME İNSURANCE LTD. does not commit NORTHPRİME İNSURANCE LTD. to execute

the insurance contract, that the application form/proposal must be delivered to NORTHPRİME İNSURANCE LTD. at latest within 5 days following the date

of completion thereof and that if this period is exceeded, my application will be rejected.

Documents required for application

Photocopy of passport

Recent Student Letter (valid up to 3 month)

Health insurance payment bank receipt (50 Euro)

Policy holder’s/ Insured name and Surname

Signature

DATE

2017

Please complete this form and return to: Near East University International Students Office, Ms. Malika Sadikova/Mrs. Verda

Gumush Ozatach. Alternatively, you can email the completed form, required documents and any queries to

malika.sadikova@neu.edu.tr

verda.ozatac@neu.edu.tr

Emergency Health Insurance Form

Related Articles

Related forms

Related Categories