Health Insurance Online Application

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Policy Holder Information

Note: all fields are mandatory unless otherwise specified

I am applying:
Please select an option

Policy Holder Name:
Please enter the name of the Policy Holder or if joining an Employer Policy the name of your Employer.

Please enter the name of the Policy Holder or if joining an Employer Policy the name of your Employer.

Policy Holder Name
Enter the policy holder name

The name of the owner of the policy, this could be a family member or the name of your employer.

Policy Holder Information
Input Valid formats:

Enter the policy holder email

Select the effective date

Billing Address
Please enter your address.

Personal Information

Please enter information of insured persons.

Enter a first name

enter family name

Enter insured person's email

Input Valid formats:

Enter your occupation and job title

Select the gender

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Select the relationship

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Enter the height in centimetre

Enter your weight in Kg

Enter the Passport/Government ID Number

Select the Country of Passport

Select a Country of Residence

Enter insured person's address

Applicant Medical and Lifestyle Questionnaire

Are you currently covered by any medical insurance policy?

Please select Yes or No

Please provide us with a scan copy of the policy and benefits schedule via email to inquiry@pacificcross.com

Has any medical or life application been declined, rated or restricted?

Please select Yes or No

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Has any medical or life policy been cancelled, withdrawn, rated or restricted?

Please select Yes or No

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At any time prior to this application, have you ever had symptoms of or been diagnosed, investigated or treated for any of the following

speech defect, paralysis, hearing loss, physical defect, infirmity, congenital illness, genetic deformity or disease or chronic condition?

Please select Yes or No

When was the initial onset of the condition and what was the exact diagnosis made by the doctor including any identified underlying cause?

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What treatment, medication, test, surgery did you receive?

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When and where was the last time you visited your doctor for this condition?

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Do you currently have any on-going treatment for this condition? If yes, please provide the details.

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What is the current status of this condition; are there any ongoing complications or limitations to your health from this condition?

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asthma, respiratory or allergic condition or disorder of the eyes, ears, nose or throat?

Please select Yes or No

When was the initial onset of the condition and what was the exact diagnosis made by the doctor including any identified underlying cause?

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What treatment/medication/test/surgery did you receive?

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When and where was the last time you visited your doctor for this condition?

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Do you currently have any on-going treatment for this condition? If yes, please provide the details.

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What is the current status of this condition; are there any ongoing complications or limitations to your health from this condition?

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psychiatric or mental disorder, fainting, blackout, mood change, drug/alcohol addiction, seizure or fit?

Please select Yes or No

When and where was the last time you visited your doctor for this condition?

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Do you currently have any on-going treatment for this condition? If yes, please provide the details.

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What is the current status of this condition; are there any ongoing complications or limitations to your health from this condition?

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When was the initial onset of the condition and what was the exact diagnosis made by the doctor including any identified underlying cause?

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What treatment/medication/test/surgery did you receive?

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hypertension, high/low blood pressure, chest pain, cholesterol problem, dizziness, heart or circulatory disorder?

Please select Yes or No

When was the initial onset of the condition and what was the exact diagnosis made by the doctor including any identified underlying cause?

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What treatment/medication/test/surgery did you receive?

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When and where was the last time you visited your doctor for this condition?

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Do you currently have any on-going treatment for this condition? If yes, please provide the details.

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What is the current status of this condition; are there any ongoing complications or limitations to your health from this condition?

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kidney stone, venereal disease, or disorder of the bladder, prostate, kidney or genito-urinary tract?

Please select Yes or No

When was the initial onset of the condition and what was the exact diagnosis made by the doctor including any identified underlying cause?

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What treatment/medication/test/surgery did you receive?

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When and where was the last time you visited your doctor for this condition?

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Do you currently have any on-going treatment for this condition? If yes, please provide the details.

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What is the current status of this condition; are there any ongoing complications or limitations to your health from this condition?

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hepatitis, ulcer, hemorrhoid, colitis or stomach, gall bladder, liver or bowel disorder?

Please select Yes or No

When was the initial onset of the condition and what was the exact diagnosis made by the doctor including any identified underlying cause?

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What treatment/medication/test/surgery did you receive?

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When and where was the last time you visited your doctor for this condition?

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Do you currently have any on-going treatment for this condition? If yes, please provide the details.

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What is the current status of this condition; are there any ongoing complications or limitations to your health from this condition?

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sciatica, back pain, joint pain or rheumatic, arthritic, muscle, joint or bone disease or disorder?

Please select Yes or No

When was the initial onset of the condition and what was the exact diagnosis made by the doctor including any identified underlying cause?

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What treatment/medication/test/surgery did you receive?

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When and where was the last time you visited your doctor for this condition?

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Do you currently have any on-going treatment for this condition? If yes, please provide the details.

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What is the current status of this condition; are there any ongoing complications or limitations to your health from this condition?

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blood abnormality or blood vessel disorder?

Please select Yes or No

When was the initial onset of the condition and what was the exact diagnosis made by the doctor including any identified underlying cause?

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What treatment/medication/test/surgery did you receive?

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When and where was the last time you visited your doctor for this condition?

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Do you currently have any on-going treatment for this condition? If yes, please provide the details.

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What is the current status of this condition; are there any ongoing complications or limitations to your health from this condition?

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HIV, AIDS, AIDS Related Complex, or any indication of blood or immune system disorder?

Please select Yes or No

When was the initial onset of the condition and what was the exact diagnosis made by the doctor including any identified underlying cause?

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What treatment/medication/test/surgery did you receive?

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When and where was the last time you visited your doctor for this condition?

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Do you currently have any on-going treatment for this condition? If yes, please provide the details.

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What is the current status of this condition; are there any ongoing complications or limitations to your health from this condition?

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cancer, tumor or cyst?

Please select Yes or No

When was the initial onset of the condition and what was the exact diagnosis made by the doctor including any identified underlying cause?

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What treatment/medication/test/surgery did you receive?

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When and where was the last time you visited your doctor for this condition?

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Do you currently have any on-going treatment for this condition? If yes, please provide the details.

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What is the current status of this condition; are there any ongoing complications or limitations to your health from this condition?

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skin disorder?

Please select Yes or No

When was the initial onset of the condition and what was the exact diagnosis made by the doctor including any identified underlying cause?

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What treatment/medication/test/surgery did you receive?

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When and where was the last time you visited your doctor for this condition?

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Do you currently have any on-going treatment for this condition? If yes, please provide the details.

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What is the current status of this condition; are there any ongoing complications or limitations to your health from this condition?

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diabetes mellitus, glandular or hormonal disorder?

Please select Yes or No

When was the initial onset of the condition and what was the exact diagnosis made by the doctor including any identified underlying cause?

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What treatment/medication/test/surgery did you receive?

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When and where was the last time you visited your doctor for this condition?

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Do you currently have any on-going treatment for this condition? If yes, please provide the details.

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What is the current status of this condition; are there any ongoing complications or limitations to your health from this condition?

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rheumatic fever, gout, malaria or hernia of any kind?

Please select Yes or No

When was the initial onset of the condition and what was the exact diagnosis made by the doctor including any identified underlying cause?

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What treatment/medication/test/surgery did you receive?

Invalid Input

When and where was the last time you visited your doctor for this condition?

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Do you currently have any on-going treatment for this condition? If yes, please provide the details.

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What is the current status of this condition; are there any ongoing complications or limitations to your health from this condition?

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gynecological disorder or disease or complication associated with pregnancy?

Please select Yes or No

When was the initial onset of the condition and what was the exact diagnosis made by the doctor including any identified underlying cause?

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What treatment/medication/test/surgery did you receive?

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When and where was the last time you visited your doctor for this condition?

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Do you currently have any on-going treatment for this condition? If yes, please provide the details.

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What is the current status of this condition; are there any ongoing complications or limitations to your health from this condition?

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any other ailment, impairment, or injury?

Please select Yes or No

When was the initial onset of the condition and what was the exact diagnosis made by the doctor including any identified underlying cause?

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What treatment/medication/test/surgery did you receive?

Invalid Input

When and where was the last time you visited your doctor for this condition?

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Do you currently have any on-going treatment for this condition? If yes, please provide the details.

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What is the current status of this condition; are there any ongoing complications or limitations to your health from this condition?

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Are you currently undergoing any investigations or taking any medications or receiving any form of treatment recommended or prescribed?

Please select Yes or No

please provide further information related to treatment including any medication you are currently taking (list with dosage)

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Have you been a patient in a hospital or sanitarium for surgery, observation or treatment in the last 5 years?

Please select Yes or No

please provide further information

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Have you ever smoked or otherwise used tobacco?

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Please advise the consumption (pack) and duration of tobacco use

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Personal Physician Information (optional)

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Personal Accident Benefit


Would you like to be covered by an additional Personal Accident Benefit?

Please select Yes or No

Input Amount:
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Personal Accident Benefits pays out a lump sum to a beneficiary in the event of death or Permanent Disability due to an Accident. For more information on what is covered please refer to the Policy Wording Document?

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Plan Choice

Please select an insurance plan

Note: you can select more than one discount, upgrade and benefit.

Discount Options

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Upgrade Benefits

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Optional Benefits

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Discount Options

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Upgrade Benefits

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Optional Benefits

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Discount Options

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Upgrade Benefits

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Discount Options

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Upgrade Benefits

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Up to

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Optional Benefits

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I hereby apply for a policy to be based on the above statements and declare that, to the best of my knowledge and belief, all answers to the foregoing questions are correctly and accurately recorded, and that they are full, complete and true.

Please confirm

I hereby authorize any licensed physician, medical practitioner, hospital, clinic or other medical or medically related facility, insurance company or other organization, institution or person, that has any records or knowledge of me or my health, to give to PACIFIC CROSS INSURANCE COMPANY LIMITED any such information. A photostat copy of this authorization shall be as valid as the original.

Please confirm

Name of the person who completed the application

Enter your name

Broker Name or Number (if applicable)

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Date of Application

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