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13th June 2007

MultiTrip Application Form

Please use Block Capitals.

This form is to be completed by applicants over 65+ years. For details of cover for under 65’s phone CallSave 1850 44 44 44.

Details of payment must be completed for policy to be registered.

Note: All persons included on a Multi Trip policy must be covered by a current Vhi Healthcare Hospital Plan i.e. Plans A-E, A-E Option or LifeStage Choices Plans.

Method of Payment

Card No.:

Laser Visa

MasterCard

Each applicant on a ‘couple’ policy must be aged 65+ years.

Please state your Vhi Healthcare membership no.:

Expiry Date:

Mr. Mrs. Miss Ms.:

First Name:

Annual Direct Debit via credit/laser card

Yes*

By choosing Yes* you are guaranteeing continuous cover from your Multi Trip policy.

No

Surname:

Cardholder’s Name:

Address:

Cardholder’s X Signature:

Date:

Cheque (Please make your cheque payable to Vhi Travel Insurance.)

Date of Birth:

Occupation:

*I authorise Vhi Healthcare to debit my credit/laser card with the appropriate amount (amount may vary annually) on an annual renewal basis until further notice in writing.

Daytime Telephone No.:

To be Signed by the Applicant

Evening Telephone No.:

I agree to be bound by the terms and conditions as contained in the Multi Trip Travel Insurance Policy Document.

E-mail Address:

I declare that to the best of my knowledge and belief the information provided is true and complete and the applicant has not concealed anything material from the insurers.

Policy Effective Date

Please select a date, month and year you would like your policy to be effective from. To fully avail of your cancellation/curtailment benefit it is advised that your policy effective date is before your booking date of trip.

DATE (please circle a date)

MONTH

YEAR

X Signature:

Date:

  • Will be sent on registration or may be had, in advance, on request.

For Office Use Only:

1

8

15

22

Policies can only be made effective on certain dates of each month.

Additional Person to be Insured

FULL NAME

DATE OF BIRTH

RELATIONSHIP

PLAN

AREA OF COVER

OPTIONAL ADD-ONS

INDIVIDUAL

WORLDWIDE

GOLF COVER

COUPLE

EUROPE

MOTOR BREAKDOWN

VHI POLICY NO.

Level of Cover Required (Tick appropriate box(es))

Note: Optional add-ons can only be purchased in addition to your Multi Trip product.

Add-ons are charged on the basis of your plan, e.g. couple rate for couple policy, even if one applicant requires the cover.

Principal Exclusions & Conditions

Note: The terms and conditions of this policy differ from the Vhi Healthcare Hospital Plans and you need to be aware of both.

  • 30 day single trip limit, maximum 180 days travel p.a.

  • No Extended Trip Limit cover for members over 80 years

  • Policyholders and any added person must be aged 65+ years

  • There is no refund on any cancelled policies 14 days beyond receipt of policy

  • €65 excess per benefit per person

  • All persons included on a Multi Trip policy must be covered by a current Vhi Healthcare Hospital Plan. Plan P members are not entitled to cover under Multi Trip

  • Medical Emergencies are handled through Vhi Assist under your Vhi Healthcare Hospital Plan

  • Cancellation of your Vhi Healthcare Hospital Plan will result in non-refundable cancellation of your travel policy

  • Please note that for members over 80 years of age, additional terms and conditions apply

Vhi Healthcare may wish to send you information, which we believe may be of interest to you. If you do not wish to receive this information, please tick the appropriate box(es) below:

I do not wish to receive details of Vhi Healthcare products and services

I do not wish to receive details of non-Vhi Healthcare products and services

Data Protection Acts

Information obtained by Vhi Healthcare and Europ Assistance becomes part of the data we hold for the purpose of administering healthcare-related insurance. In accordance with the Data Protection Acts, 1988 and 2003 details of our use of personal data appear in the public register held by the Data Protection Commissioner.

Vhi Healthcare and Europ Assistance Ltd. may disclose information on a strictly confidential basis for the purpose of research, statistics or suspected fraud as follows:

  • Anonymised medical information to those involved with your treatment or care.

  • Anonymised non-medical information to others for the purpose of efficient administration

(for example: audit, systems development, administration).

  • Other insurance companies and/or the relevant authorities (for example An Garda Síochána).

If you have any queries about your data, please write to the Data Manager, Vhi Healthcare, Vhi House, Lower Abbey Street, Dublin 1.

For Office Use Only Reference No.:

S.P.I.N.:

Membership No.:

Application Date:

Comp. By:

Vhi Healthcare is an agent of Europ Assistance Holding Irish Branch for non-life business. The information overleaf is issued as a guide only and does not form part of a contract. The Voluntary Health Insurance Board (trading as Vhi Healthcare) is a Multi-Agency Intermediary regulated by the Financial Regulator.

SB65MT9

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