International Private Medical Insurance 1st Euro

2013

Your mobility partner.

PANDA ASIA EXPAT CARE

www.panda-expat-insurance.com

Hot line: +33 (0)3 28 04 69 85

BANGKOK:

PANDA INTERNATIONAL EXPAT

(Thailand) Co.,Ltd

Metropark 206/77 Kallaprapruk

Road, Pasi Jaroen, Bang Wa

Bangkok 10160 - Thailand.

Tel.: +66 (0)2 458 81 54

Fax: +66 (0)2 458 89 44

asia@panda-expat-insurance.com

PARIS:

GAPI - 58 rue de l’arcade

75008 PARIS

Tel.: + 33 (0)1 44 69 50 20

Fax: +33 (0)1 44 69 05 93

contact@gapigestion.com

International Private Medical

sement

2013

PANDA ASIA EXPAT CARE

Individual application form 1/2

Document to be returned to the administrative center: GAPI - 58 rue de l’Arcade – 75008 Paris [France].

PANDA INTERNATIONAL EXPAT (Thailand) Co.,Ltd - Metropark 206/77 Kallaprapruk Road, Pasi Jaroen, Bang Wa - Bangkok 10160 [Thailand].

INSURANCE BROKER

MEMBER

FAMILY MEMBERS

GUARANTEES CHOSEN

PREMIUMS

REIMBURSEMENT OF BENEFITS

PAYMENT OF PREMIUMS

Desired date of membership:

Health Care

Spouse: Child 1: Child 2: Child 3: Child 4:

PERSONS TO BE INSURED: SURNAME, FORENAME French social security no.

Address for sending claim statements:

Address for sending premium advice notes:

Means of reimbursement:

Payment periods: Payment currency:

Payment currency:

SEX DATE OF BIRTH

M

F

M

F

M

F

M

F

M

F

Policy: PREMIUM CONFORT SUMMUM

Geographical scope: Area A Area B Area C

Geographical of coverage: Area 1 Area 2

Annual deductible: None 150 € €300

Membership: Individual Family

Assistance

YES NO Individual Family

Geographical of coverage: Area A Area B Area C

Third-party liability insurance

YES NO Individual Family

Chèque

Annual Euro

Euro

Bank transfer

(enclose a “RIB” [bank account details])

6-monthly 3-monthly Other:

Other:

1st Euro

Type of guarantee: CFE complementary insurance (if other, please specify):

Health premium amount per month:: Third-party liability premium amount per month:

Assistance premium amount per month: Euro incl. tax

Euro incl. tax

Euro incl. tax

Street:

Postal Code: Town:

Street:

Postal Code: Town:

Official stamp:

Surname:

If you have a french social security number:

Occupation: Address:

Postal Code: Town:

Forename:

Date of birth: Nationality:

Country of expatriation:

Tel.: Fax:

2013

PANDA ASIA EXPAT CARE

Individual application form 2/2

DIRECT DEBIT AUTHORISATION

Surname, forename and address of the debtor:

Account to be debited:

Name and address of the creditor:

Done at: on [date]:

Date:

I certify that:

- I am physically able to carry out a full-time job;

- all the statements and answers provided on the membership form and on the medical questionnaire are true and, to my knowledge, complete and accurate; - I am covered by the group health insurance policy no. 7163221 taken out by ASPI with Equity;

- I am covered by the IMA Assistance policy if the Assistance option has been subscribed to;

- I am covered by the TOKIO MARINES third-party liability insurance policy no. 35524910 if the Third-party liability option has been subscribed to; and - I have received a copy of the information note checked below:

HEALTH: EQ/AT/0531A DG ASPI ASSISTANCE: IMA ASSISTANCE DG ASPI RC: TMSL-RCEXP-06/10

- I authorise GAPI to receive on my behalf all reimbursement statements from the CFE [French Nationals Abroad Fund] or from the French Primary Health Insurance fund and to directly receive from said services the reimbursements of any hospital fees for which I am entitled to third-party payment.

I am entitled, in accordance with the French Data Protection Law of 6 January 1978, to ask GAPI to send me and to correct any information about me contained in any files used by the Company, the administrator and/or its correspondents. This right of access and rectification can be exercised by writing to the following address: GAPI – 58 rue de l’Arcade – 75008 Paris [France].

I also declare:

1/ that by signing this document, provided that the membership application is complete and accepted by the Company, I am requesting that the insurance

guarantees become effective for the period of a calendar quarter, and that it be tacitly renewed each quarter subject to payment of the premium. The

effective date will be validated on presentation of the membership certificate.

2/ that, by way of exception, in the event that the membership certificate has not been presented because the conditions of insurability were such that the insurer was unable to reach an immediate decision, I should return the letter informing me of the specific provisions for risk acceptance with the mention “Agreed”. The Company’s final commitment will then become binding with the sending of the membership certificate mentioning the new conditions of insurability. The contract will be deemed concluded at the date of signature by the insured of the said letter.

In any event, the insurer is not bound by this membership application, even if it is accompanied by payment, notably and including if the insurer has accepted and/or cashed payment. The insurer’s commitment only becomes binding with the issuance of the membership certificate. The guarantees will become effective on the date mentioned on this certificate, which may be different from that of the conclusion of the contract, subject to receipt of the first payment.

Any misgivings, omissions or misstatements will result in the application of the relevant sanctions provided for in Articles L. 113-8 and L. 113-9 of the French Code of Insurance.

I authorise the Financial Institution, holder of my account, to withdraw from the latter, should the balance enable such a transaction, all quarterly premium amounts payable to the creditor named below. In the event of disagreement concerning a debit transaction, I may suspend execution thereof upon simple request to the Financial Institution, holder of my account. It will then be my duty to solve the problem directly with the creditor. This authorisation will remain valid until cancelled by myself, as I may deem necessary, with the creditor.

Health cover is granted by the L’EQUITE insurance company, French Public Limited Company [SA] with a capital of €15,569,320 – Paris Trade & Company Register [RCS] no. 572 084 697 – Company governed by the French Code of Insurance – Head Office: 7 boulevard Haussmann, 75442 Paris Cedex 09. Company belonging to the Generali Group, listed in the Italian Insurance Group Register under number 026.

Assistance cover is granted by IMA : INTER MUTUELLE ASSISTANCE, French Limited company (SA) with a capital of € 7.000.000 – Niort Trade & Company register (RCS) 481 511 632 – Company governed by the French code of Insurance - Head office: 118 avenue de Paris, 79000 NIORT.

Private third-party liability cover is granted by TOKIO MARINE EUROPE Insurance Limited (UK), UK Public Limited Company – Head Office: 150 Leadenhall Street, London EC3V 4TE – Company Registration no. 989421 England – Share Capital: £35,000,000 – Company authorised and regulated by the UK Financial Services Authority (FSA) and acting in accordance with the rules of the French Code of Insurance. French branch main office: 66 rue de la Chaussée d’Antin, 75441 Paris Cedex 09 – Paris Trade & Company Register [RCS] no. B382 096 071.

Signature of the member(preceded by the mention “read and approved”)

Mandatory signature:

N° NATIONAL D’EMETEUR: 519369

GAPI

58, rue de l’Arcade - 75008 PARIS - France

Bank Code Branch Account no.

Account key code

Name and postal address of the financial institution, holder of the account to be debited

2013

PANDA ASIA EXPAT CARE

IMPORTANT:

this questionnaire must completed manually. Strikethrough is not allowed.

All questions have to be answered. Tick the relevant box.

When answering

YES

to one or several questions (except to question 14) please provide all additional details at point 15 (date, reason, type of treatment

or analysis, follow-up or after-effects, etc...) dated and signed in your own handwriting, clearly indicating which question(s) the information refers to.

You can send this health questionnaire and the additional details you provide by sending them in a sealed envelope to the Medical Examiner of the

administrator company G.A.P.I. – 58, rue de l’Arcade – 75008 Paris.

PLEASE READ CAREFULLY THE FOLLOWING QUESTIONNAIRE

This questionnaire must be dated and signed. All questions must be answered.

POLICY APPLICANT - 1/2

(this questionnaire is contains 2 pages)

Dependant 3

Dependant 2

Dependant 1

Member

Initials:

Applicant’s NAME and FIRST NAME:

Medical questionnaire

How much do you weigh?

How tall are you?

Are you currently on sick leave?

Do you currently benefit full coverage

from your National Health service?

Are you currently pregnant?

Over the past 3 years, have you ever been on sick leave

for a period exceeding 30 days?

Over the past 10 years, have you ever been admitted for surgery

(other than for the removal of your appendix,

tonsils, adenoids or gall-bladder)?

Are you expecting to be admitted for surgery in the near future? If yes, when?

Over the past 10 years, have you ever been admitted to a hospital, clinic, sanatorium

or spa centre?

Are you expecting to be admitted to such establishments in the near future? If yes, when?

Over the past 10 years, have you ever been ill, suffered from ailments or been victim

of an accident, giving rise to medical supervision for more than 30 days?

Are you currently under medical surveillance (treatments, care)

and/or are you taking medicine prescribed by a doctor

(other than birth-control pills)?

Do you currently suffer from any one of the following illnesses or complaints:

cardiovascular, digestive, kidney, joints, diabetes, nervous system, respiratory/lungs,

hypertension, endocrinology, haematology?

Over the past 5 years, have you ever had a biological test and/or a serologic test,

which have not been normal?

Do you benefit from an invalidity pension exceeding 15% from the either

the armed forces or the civil authorities?

Are you properly vaccinated regarding your next trip abroad?

Do you have any tooth problems? If yes, please indicate the treatment in progress

or planned. When was your last dental check-up?

YES NO YES NO YES NO YES NO YES NO YES NO YES NO YES NO YES NO YES NO YES NO YES NO YES NO YES NO YES NO YES NO YES NO YES NO YES NO YES NO YES NO YES NO YES NO YES NO YES NO YES NO YES NO YES NO YES NO YES NO YES NO YES NO YES NO YES NO YES NO YES NO YES NO YES NO YES NO YES NO YES NO YES NO YES NO YES NO YES NO YES NO YES NO YES NO YES NO YES NO YES NO YES NO YES NO YES NO YES NO YES NO YES NO YES NO YES NO YES NO

2013

PANDA ASIA EXPAT CARE

POLICY APPLICANT - 2/2

Nota: make sure you enclose both sheets of this questionnaire, for yourself and for your spouse, along with your individual application form.

L’ÉQUITÉ assurances,

L’Équité, public limited company with a capital of 18,469,320 euros Business governed by the French insurance Code B 572 084 697 RCS Paris -Head Office: 7 boulevard Haussmann - 75442 Paris Cedex 09

Business belonging to Generali group, registered in Italy under n° 026 of Insurance groups

ASSUR-TRAVEL

SAS with a share capital of 38.000 € - 451 947 378 RCS LILLE - Head office: 49, boulevard de Strasbourg - 59000 LILLE Tel. 03 20 34 67 48 - Fax : 03 20 64 29 17 - N°Orias 07030650 – www.orias.fr

GAPI

Public limited company with a capital of €5000 - 490 676 228 RCS PARIS - Head office: 58, rue de l’Arcade - 75009 PARIS - Tel. 01 44 69 50 20 - Fax : 01 44 69 05 93

Je certifie que toutes les déclarations ou réponses faites ci-dessus sont sincères et, à ma connaissance, complètes et exactes. Je déclare ne pas ignorer que si, dans l’appréciation des risques, L’EQUITE a été induit en erreur par suite d’une fausse déclaration intentionnelle ou d’une réticence, l’assurance pourra être annulée aux conditions prévues par le Code des Assurances (Articles L.113-8 et L.113-9).

Medical questionnaire

ADDITIONAL INFORMATION:

Done at:

Applicant’s NAME and FIRST NAME:

Applicant’s signature

(preceded by the wording “Read and approved”)

2013

PANDA ASIA EXPAT CARE

IMPORTANT:

this questionnaire must be completed manually. Strikethrough is not

allowed. All questions have to be answered. Tick the relevant box.

When answering

YES

to one or several questions (except to question 14) please provide all additional details at point 15 (date, reason, type of treatment

or analysis, follow-up or after-effects, etc...) dated and signed in your own handwriting, clearly indicating which question(s) the information refers to.

You can send this health questionnaire and the additional details you provide by sending them in a sealed envelope to the Medical Examiner of the

administrator company G.A.P.I. – 58, rue de l’Arcade – 75008 Paris.

PLEASE READ CAREFULLY THE FOLLOWING QUESTIONNAIRE

This questionnaire must be dated and signed. All questions must be answered.

APPLICANT’S SPOUSE - 1/2

(this questionnaire is composed of 2 pages)

Dependant 1*

* child tied to spouse, though not appearing on the member’

s questionnair

e.

Initials:

Applicant’s NAME and FIRST NAME:

Spouse NAME and FIRST NAME:

Member’s

spouse

Medical questionnaire

Dependant 2* Dependant 3*

How much do you weigh?

How tall are you?

Are you currently on sick leave?

Do you currently benefit fro full coverage

from your National Health service?

Are you currently pregnant?

Over the past 3 years, have you ever been on sick leave

for a period exceeding 30 days?

Over the past 10 years, have you ever been admitted for surgery

(other than for the removal of your appendix,

tonsils, adenoids or gall-bladder)?

Are you expecting to be admitted for surgery in the near future? If yes, when?

Over the past 10 years, have you ever been admitted to a hospital, clinic, sanatorium

or spa centre?

Are you expecting to be admitted to such establishments in the near future? If yes, when?

Over the past 10 years, have you ever been ill, suffered from ailments or been victim

of an accident, giving rise to medical supervision for more than 30 days?

Are you currently under medical surveillance (treatments, care)

and/or are you taking medicine prescribed by a doctor

(other than birth-control pills)?

Do you currently suffer from any one of the following illnesses or complaints:

cardiovascular, digestive, kidney, joints, diabetes, nervous system, respiratory/lungs,

hypertension, endocrinology, haematology?

Over the past 5 years, have you ever had a biological test and/or a serologic test,

which have not been normal?

Do you benefit from an invalidity pension exceeding 15% from the either

the armed forces or the civil authorities?

Are you properly vaccinated regarding your next trip abroad?

Do you have any tooth problems? If yes, please indicate the treatment in progress

or planned. When was your last dental check-up?

YES NO YES NO YES NO YES NO YES NO YES NO YES NO YES NO YES NO YES NO YES NO YES NO YES NO YES NO YES NO YES NO YES NO YES NO YES NO YES NO YES NO YES NO YES NO YES NO YES NO YES NO YES NO YES NO YES NO YES NO YES NO YES NO YES NO YES NO YES NO YES NO YES NO YES NO YES NO YES NO YES NO YES NO YES NO YES NO YES NO YES NO YES NO YES NO YES NO YES NO YES NO YES NO YES NO YES NO YES NO YES NO YES NO YES NO YES NO YES NO

2013

PANDA ASIA EXPAT CARE

APPLICANT’S SPOUSE - 2/2

Nota: make sure you enclose both sheets of this questionnaire, for yourself and for your spouse, along with your individual application form.

L’ÉQUITÉ assurances,

L’Équité, public limited company with a capital of 18,469,320 euros Business governed by the French insurance Code B 572 084 697 RCS Paris -Head Office: 7 boulevard Haussmann - 75442 Paris Cedex 09

Business belonging to Generali group, registered in Italy under n° 026 of Insurance groups

ASSUR-TRAVEL

SAS with a share capital of 38.000 € - 451 947 378 RCS LILLE - Head office: 49, boulevard de Strasbourg - 59000 LILLE Tel. 03 20 34 67 48 - Fax : 03 20 64 29 17 - N°Orias 07030650 – www.orias.fr

GAPI

Public limited company with a capital of €5000 - 490 676 228 RCS PARIS - Head office: 58, rue de l’Arcade - 75009 PARIS - Tel. 01 44 69 50 20 - Fax : 01 44 69 05 93

Je certifie que toutes les déclarations ou réponses faites ci-dessus sont sincères et, à ma connaissance, complètes et exactes. Je déclare ne pas ignorer que si, dans l’appréciation des risques, L’EQUITE a été induit en erreur par suite d’une fausse déclaration intentionnelle ou d’une réticence, l’assurance pourra être annulée aux conditions prévues par le Code des Assurances (Articles L.113-8 et L.113-9).

Medical questionnaire

ADDITIONAL INFORMATION:

Done at:

Applicant’s NAME and FIRST NAME:

Spouse NAME and FIRST NAME:

Signature of Applicant’s spouse

(preceded by the wording “Read and approved”)