WC

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Personal Details

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Date of Birth:*
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Agent Details

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Dependent Details

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Children Coverage Required?:*

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First Name:*	Middle Name:	Last Name:*
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Coverage Details


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Consent for Use and Disclosure of Your Health Information

The following consent for use and disclosure of your personal information does not apply to residents of the UK. Please tick this box if you are a UK resident to continue with the request for quote and application.

Application for this plan of benefits may require that you provide us with sensitive personal information about you and your enrolling dependents. In accordance with the privacy policy posted on our website, we will require your consent and the consent of those dependents you are applying for to process this application.

In the event that your application is approved we will require your continuing consent to administer your plan and this will include pre-authorization of medical services, claims administration and appeals.

Our privacy policy provides information concerning the use and disclosure of your personal information including your rights under this policy. This privacy policy is in compliance with GBG’s data protection policies and those of the European Union (EU) General Data Protection Regulation (GDPR). Throughout the year the terms of the privacy policy may be updated. You can find the most recent version at our website http://gbg.com/#/AboutGBG/PrivacyPolicy.

Your personal information, including special category or sensitive personal information such as medical and health details which you supply to the insurer may be used in many ways including, but not limited to: processing and underwriting your application for insurance, deciding whether an offer of insurance coverage can be made and on what terms, administering your policy and handling claims, and detecting and preventing fraudulent activity. Other GBG affiliates and third parties who provide services to the insurer could use your information in the same manner and further detail in respect of the transfer of your data to third parties is contained in the privacy policy.

By ticking the box “I CONSENT”, you consent to the use and disclosure of your healthcare information in accordance with our privacy policy. If you do not consent to the use and disclosure of your healthcare information GBG will not be able to evaluate your request and therefore will not be able to provide you with insurance cover. The following application should only be completed if you are willing to provide consent.

	30-Apr-2024
Applicant Signature	Date

I CONSENT