SimpleCare application form:

Individuals and families (FMU)

For company use – intermediary details and stamp

Intermediary company: Fax number:

Email address:

Contact name: Official stamp:

Telephone number:

Please complete this form in BLOCK CAPITALS or apply online at www.now-health.com.

A deliberate or reckless misrepresentation by You may lead to Us voiding Your Plan with loss of premium. Where You make a careless misrepresentation
We may void Your Plan or decline or reduce related claim payments. A misrepresentation is an untrue statement of fact relied on by one party, in this case
Us, in establishing the terms of a contract (Your Plan). You should ensure that You complete Your application carefully, accurately and fairly. If You are
unsure on any matter You should contact Us.
Please keep a record of all information You supply to Us in connection with this application.
Please enclose any medical reports or test results with Your application if they are available. We may ask You to complete a further medical questionnaire
if We need more information. All the information You provide will be treated in strict confidence.
We rely on the information that You provide in this form (i.e. Your representations) to decide whether or not to accept Your application, and whether or not
We need to apply special terms. Special terms are exclusions or conditions that We may apply to Your cover. If You submit a claim for the Treatment of any
existing condition which You did not tell Us about here or did not tell Us everything about, We may refuse to pay that claim. We also have the right to void
Your Plan, or We may impose special terms on Your Plan which We will apply retrospectively. Please take the greatest care to ensure that this application
form is completed fully and accurately.
If, after completing Your application form and before the latest of either Our written acceptance, payment of premium or Your Start Date/Entry Date,
anything occurs which affects the information You provided in this form, such as a change in Your state of health or the state of health of any of
Your Dependants, You must tell Us in writing about the change.
If You have used an authorised insurance broker You understand, acknowledge and agree that by buying this Plan, We will pay the authorised insurance broker
commission during the life of the Plan including renewals. You also understand that this agreement is necessary for Us to proceed with Your application.
We reserve the right to decline or accept Your application or to accept Your application form with special terms.
Please send Your completed application form along with a copy of Your government issued identity document to Us via Your intermediary, or direct to
Now Health International (Singapore) Pte. Ltd., 4 Robinson Road, #07-01A/02 The House of Eden, Singapore 048543. You can also scan and email it to
[email protected].

Section 1: Name of Planholder

First name(s): Family name:

What do You like to be called?

(If Your full name is John Andrew Smith, You might like to be called John or Mr Smith or Andy. We will address all correspondence to You in this way.)

Section 2: Planholder details

Address:

Email address:

Preferred telephone number (including country code):

If You would like SMS notifications,

Is this Your Mobile Home Work please tell us Your mobile number:

Gender: Male Female Date of birth (dd/mm/yyyy): / /

Country of Residence: Nationality:

Height (cm/ft): Weight (kg/lbs):

Occupation: Occupation industry:

Are You or any intended member of this policy, or any family member or close associate a politically exposed person? Yes No
(If yes please provide further details)

Page 1 of 8
Section 3: Spouse and Dependant details

Spouse details

First name(s): Family name:

What does he/she like to be called?

Gender: Male Female Date of birth (dd/mm/yyyy): / /

Country of Residence: Nationality:

Height (cm/ft): Weight (kg/lbs):

Occupation: Occupation industry:

Are You or any intended member of this policy, or any family member or close associate a politically exposed person? Yes No
(If yes please provide further details)

Dependant details Dependant 1 Dependant 2 Dependant 3 Dependant 4

First name(s):

Family name:

What do they like to be called?

Gender: Male Female Male Female Male Female Male Female

Date of birth (dd/mm/yyyy): / / / / / / / /

Country of Residence:

Nationality:

Height (cm/ft):

Weight (kg/lbs):

Relationship to Planholder:

Occupation (ages 16+):

Section 4: Start Date

Date on which You wish Your Now Health International Plan to start (dd/mm/yyyy): / /

Cover cannot start until You have accepted all of Our terms and conditions following Our receipt of this application form and We have received the correct
premium. You can apply for cover to start at a future date within 60 days of completion of this application form.

Section 5: Our environmental policy – Your document delivery settings

You can use Your secure online portfolio to view and download Your Plan documents, including Your Certificate of Insurance

You can use Your secure online portfolio to download Your virtual membership card.

Add Your membership card to Your smartphone wallet

Page 2 of 8
Section 6: Plan options

For detailed information about the Plan choices available, please refer to SimpleCare Benefit Schedule. Please indicate Your Plan choice, Deductible, any
Out-Patient option and/or Additional option.

6.1 Choice of Group Plan

SimpleCare SimpleCare SimpleCare

Benefit
CORE 100 250
USD 1,000,000/ USD 1,500,000/ USD 1,500,000/
Annual Maximum Plan Limit
SGD 1,300,000 SGD 1,950,000 SGD 1,950,000

Area of Cover: Worldwide excluding USA

Treatment in Singapore
In-Patient and
(i) Singapore Public Hospital (i) Nil (i) Nil (i) Nil
Day-Patient
(ii) Singapore Private Hospital (ii) 20% (ii) 20% (ii) 20%
Co-Insurance
Treatment outside Singapore Nil Nil Nil

In-Patient and Day-Patient care

Day-Patient or Out-Patient surgery

Cancer Treatment

Organ Transplant

Congenital cover

Rehabilitation

Evacuation and Repatriation

Out-Patient fees

Dental Treatment

Please Choose

Full refund Not covered Limited cover

Choice of currency USD SGD

SimpleCare SimpleCare SimpleCare

6.2 Plan Deductible*
CORE 100 250
Standard Deductible USD 500/SGD 650 USD 500/SGD 650 USD 500/SGD 650

Optional Deductible

Nil

USD 150/SGD 195

USD 250/SGD 325

USD 1,000/SGD 1,300

USD 2,500/SGD 3,250

USD 5,000/SGD 6,500

USD 10,000/SGD 13,000*

USD 15,000/SGD 19,500*

SimpleCare SimpleCare SimpleCare

6.3 Out-Patient options**
CORE 100 250
USD 25/SGD 30 Out-Patient Per Visit Excess** N/A

20% Co-Insurance Out-Patient Treatment** N/A

* If You would like to change from the Standard Deductible to one of the other options, please tick the appropriate box. Please note that the Plan Deductible
applies to In-Patient, Day-Patient and Out-Patient Treatment is per Insured Person, per Period of Cover.
USD 10,000/SGD 13,000 or USD 15,000/SGD 19,500 Deductible is only available if You are covered by more than one health insurance policy. You can only select
such Deductible options if You buy this Plan as a Secondary Health Insurance Plan.
Please note an Integrated Shield Plan is not considered as Primary Health Insurance for the purpose of purchasing this Plan as a Secondary Health Insurance Plan.
** Please note that Out-Patient Options can only be taken if You select a Deductible option of USD 500/SGD 650 or lower.

SimpleCare SimpleCare SimpleCare

6.4 Additional Option
CORE 100 250
Removal of Co-Insurance for In/Day-Patient Treatment in
Singapore Private Hospitals
Page 3 of 8
Section 7: Method and frequency of premium payment

Please note that if the payment You are to make now is based on an indicative quote the amount due may change once We have reviewed this application.
You will need to both agree and pay the revised premium before cover can start. Please select the frequency and payment type You would like to pay Your
premiums in. Please note that quarterly premiums have a 3% surcharge and monthly premiums have a 5% surcharge.

Annually Semi-annually Quarterly Monthly

Cheque N/A N/A N/A

Credit card

Bank transfer N/A N/A N/A

Cheque: Please make Your cheque payable to Now Health International (Singapore) Pte. Ltd. and attach it to this application form.
Credit card:  We accept Visa, MasterCard and American Express. We will contact you to take the required payment. Your card issuer may charge an
additional conversion or transaction fee to process this payment.
Bank transfer: Please make sure You tell Us Your family name in the transfer details and send it to the bank account below. For a USD/SGD policy,
premium needs to be paid to the respective bank accounts only.

USD account SGD account

Bank Citibank N.A. Singapore Branch Citibank N.A. Singapore Branch

Bank code N/A 7214

Branch code N/A 001

Bank account name Now Health International (Singapore) Pte. Ltd Now Health International (Singapore) Pte. Ltd

Address 8 Marina View 8 Marina View

21-01 Asia Square Tower 1 21-01 Asia Square Tower 1
Singapore 018960 Singapore 018960

Account no. 0857607104 0857607074

Swift code CITISGSG CITISGSG

Section 8: Claim reimbursement

Bank transfer - Please complete all details

Account/payee name: Payment currency:

Name of bank: Bank code: Branch code:

Branch address & country:

Bank account currency: IBAN no:

Account no: Routing code:

Local banking code: Swift code:

Any other relevant information:

Section 9: Insurance details

9.1 Do You currently have health insurance with another company? Yes No

If yes, please give details:

9.2 Do You intend to continue with the existing insurance? Yes No

9.3 Do You intend to buy this Plan as a Secondary Health Insurance Plan? Yes No

If You buy this Plan as a Secondary Health Insurance Plan, You must provide a copy of the Certificate of Insurance of Your Primary Health
Insurance policy. If You have more than one health insurance policy, this Plan will be the health insurance policy that pays last.
Please note an Integrated Shield Plan is not considered as Primary Health Insurance for the purpose of purchasing this Plan as a Secondary Health
Insurance Plan.

9.4 Have You been insured previously with Now Health International? Yes No

If yes, please give dates of when insured and previous policy number:

9.5 Have You ever had an application for Medical Insurance declined or had special terms imposed? Yes No

If yes, please give details:

Page 4 of 8
Section 10: Health declaration

If You have more than five Dependants, please use a separate sheet of paper and attach it to this application.
You do not need to disclose matters related to common colds, Vaccinations or hayfever.

Dependant Dependant Dependant Dependant Dependant

Planholder
(Spouse) 1 2 3 4

10.1 Have You in the last five years ever undergone any Surgical
Procedure, been a patient or been treated in a Hospital,
Yes Yes Yes Yes Yes Yes
clinic, sanatorium, nursing home or other medical institution
No No No No No No
where You were off work for more than one week, and/or
received more than 10 days Treatment?

10.2 Are You currently taking any kind of medication (other than
oral contraceptives), or is any Treatment or tests currently Yes Yes Yes Yes Yes Yes
being performed or planned, or any day or In-Patient No No No No No No
hospitalisation scheduled?

Have You ever received Treatment, tests or investigations for, been diagnosed with, or been hospitalised or had signs or symptoms of for:

10.3 Asthma, bronchitis, tuberculosis, pneumonia or any other Yes Yes Yes Yes Yes Yes
respiratory conditions? No No No No No No

10.4 Anxiety, depression, psychological, psychiatric, mental Yes Yes Yes Yes Yes Yes
condition, drug or alcohol addiction or abuse? No No No No No No

10.5 Blood disorders, anaemia, haemophilia, thalassemia or other

Yes Yes Yes Yes Yes Yes
abnormal blood tests? Have You ever been tested positive
for HIV, Hepatitis B or C? No No No No No No

10.6 Cancer, cyst, polyp, or any abnormal growth whether Yes Yes Yes Yes Yes Yes
cancerous or benign? No No No No No No

10.7 Digestive disorder including stomach, colon, rectum, hernia Yes Yes Yes Yes Yes Yes
or any other bowel problems? No No No No No No

10.8 Disorders of the kidneys, spleen, liver, pancreas, bladder, Yes Yes Yes Yes Yes Yes
prostate, renal or recurrent urinary conditions? No No No No No No

Yes Yes Yes Yes Yes Yes

10.9 Diabetes, thyroid disorders or weight management problems?
No No No No No No

Yes Yes Yes Yes Yes Yes

10.10 Epilepsy, multiple sclerosis or other neurological conditions?
No No No No No No

10.11 High blood pressure, heart or circulatory conditions, stroke Yes Yes Yes Yes Yes Yes
or higher than normal cholesterol level? No No No No No No

10.12 Knee, back or skin disorders, rheumatism, gout, arthritis or Yes Yes Yes Yes Yes Yes
disease of the bone, spine, joint, muscle? No No No No No No

10.13 Any type of disease, physical impairment, congenital

Yes Yes Yes Yes Yes Yes
or hereditary disorder, disability, recurrent illness, major injury
or Medical Condition not already noted above? No No No No No No

10.14 Females only

Yes Yes Yes Yes Yes Yes
Have You ever suffered from any breast or gynaecological
disorders? No No No No No No

Page 5 of 8
Additional information

If You answered ‘Yes’ to any of questions 10.1 to 10.14, please provide details in the box below.
Please provide as much detail as possible, including the date and nature of diagnosis, frequency and severity of symptoms, date of last episode as well as
details of any past, current or known future Treatment.

Member name Diagnosis Date of Treatment Date of last Any underlying Specific Outcome
(If none made consultation received treatment/ cause location on (e.g. on-going
please describe symptoms body including complete
the exact nature left or right recovery, likely
of symptoms to recur) or
suffered) for smears,
frequency
(annually,
6-monthly)

Section 11: Doctor’s contact details

Please give details of Your current usual doctor or the one who is most familiar with Your medical history.

Medical Practitioner’s details

Name: Telephone number:

Address:

Date of last attendance and reason:

Page 6 of 8
Section 12: Important notes

Buying health insurance products that are not suitable for You may impact Your ability to finance Your future healthcare needs. You should seek advice
from Us or a qualified adviser if in doubt before You sign this application form. Should You choose not to, You are taking sole responsibility to ensure that
this product is appropriate to Your financial needs and insurance objectives.
Quotations are valid for 30 days subject to the above details remaining the same and are issued in accordance with Now Health International Plan terms,
conditions and exclusions.
The premiums quoted have been calculated based on each person’s age at the date of the quotation. Premiums may be subject to change if the age of any
person increases prior to the actual Start Date of Your Now Health International Plan. Cover cannot start until You have accepted all of Our terms and
conditions following Our receipt of this application form and We have received the correct premium.

The premiums quoted have been based on Your Body Mass Index being within normal limits.

Pre-Existing Medical Conditions

Your Plan does not cover You for Treatment of Pre-Existing Medical Conditions and Related Conditions unless accepted by Us in writing.
A Pre-Existing Medical Condition means any disease, injury or illness for which:
1. You have received Treatment, test or investigations for, been diagnosed with or been hospitalised for; or
You have suffered from or experienced symptoms; whether the Medical Condition has been diagnosed or not, at any time before your Start Date/
2. 
Entry Date into the Plan.
This Plan is not a Medisave-approved Plan and You may not use Medisave Plan to pay the premium for this Plan.
If You are a citizen or permanent resident of Singapore, You are covered by MediShield Life for life, for Treatments in Singapore, regardless of pre-existing
medical conditions or other circumstances that You face. For more details on Your coverage, please visit www.medishieldlife.sg.
This is a short-term accident and health Plan and We are not required to renew this Plan. We may terminate this Plan at renewal by giving You 30 days
notice in writing.

Data Privacy
We and Your Underwriters collect personal information about You and Your Dependants (including health, bank account and occupation) in the course of
considering Your application and, if a Plan is issued to You, conducting Our relationship with You. This information will be processed for the purposes
of underwriting Your insurance coverage, managing any Plan issued and administering claims. Your information may be passed to Now Health group
companies administering Your Plan, Underwriters, Medical Practitioners, Medical Assistance Companies and Claims Administrators for these purposes,
including those located outside Singapore. The same duty of confidentiality is required of any third parties to whom the administration of Your Plan may be
subcontracted, including those based outside Singapore. Your personal details will not be disclosed to other organisations without Your consent.
You have a right of access to, and correction of, information that We hold about You. Please contact Us if You would like to exercise either of these rights.
Some of the information We collect about You may be classified as “sensitive” – that is information about racial or ethnic origin and physical or mental health.
Data protection laws impose specific conditions in relation to sensitive information, including, in some circumstances, the need to obtain Your explicit
consent before We process the information.
Important note: We regard the rights above as best practice but the legal requirements may differ in the country in which You reside. Please
contact Us for additional information regarding regulations in Your jurisdiction.

By signing this Application Form You consent to the processing and transfer of information (including sensitive information) described in this notice. Without
this consent We will not be able to consider Your application.
Now Health International group companies providing IPMI products may contact You by letter, SMS or email with details of other IPMI or related products
and services, which may be of interest to You. If You wish this to happen please tick this box . You may opt out of future marketing by contacting Us at
any time. A list of Now Health group companies, their contact details and Our Data Privacy Policy is available at www.now-health.com.

Page 7 of 8
Section 13: Declaration and authorisation

I hereby apply for cover on behalf of all the persons named in this application form for a Now Health International Plan as specified above.
I have received and read the Benefit Schedule, Terms and Conditions, Definitions, Benefits and exclusions of this Plan. I understand that the Application
Form, Certificate of Insurance, Benefit Schedule and the Members’ Handbook incorporating the Plan terms and conditions make up the contract between
Us and all form part of the Plan Agreement. I am aware that cover shall be provided in accordance with the Agreement.
• I declare that the information given in this application is true and that disclosure in respect of each person included in this application is complete,
even if some of the information provided is not in my own handwriting. I understand it is unlawful for me or my Dependants to knowingly provide
false, incomplete or misleading facts or information to Now Health International for the purpose of defrauding or attempting to defraud Now Health
International. Penalties may include imprisonment, fines, denial of coverage, rescission of Benefits and legal damages.
• I understand that I must notify Now Health International (Singapore) Pte. Ltd. of any changes in the facts contained in this application form, such as a
change in the state of health of any person named in it, before the latest of either written acceptance, payment of premium or the Start Date/Entry Date.
• F or the purpose of this application I authorise any doctor who has ever treated or advised any of the persons named in this application to provide
Now Health International with any information they may require in connection with Treatment related to any claim under this Plan. I have discussed
the terms of this authorisation with my partner and competent adult Dependants, and I have obtained their consent to the release of their healthcare
information pursuant to this authorisation.
• I declare that I have read and understood the “Your Guide to Health Insurance” Booklet, and the Members’ Handbook which contains Product
Information and Key Product Provisions, details of my rights and Your obligations to me:
– cancellation and termination rights
– complaints procedures
– law and jurisdiction of the Plan
– language of the Plan and Our service
– compensation arrangements
Plans are underwritten by Sompo Insurance Singapore Pte. Ltd. and Now Health International (Singapore) Pte. Ltd. is acting on behalf of
– 
Sompo Insurance Singapore Pte. Ltd. for the purposes of issuing and administering Plans, receiving premiums and paying claims.
• I understand that Now Health International cannot be liable and therefore will not pay claims if my Plan is lapsed should Now Health International be
unable to collect my premium for whatever reason and I do not provide Now Health International with an alternate method of payment within seven
days of Now Health International requests for alternative methods of payment.
• I agree that where medical Treatment is received within the provider network by me or any of my Dependants and, except where previously agreed
by Now Health International, it is determined that the Treatment or Medical Condition is not refundable within the terms and conditions of the Plan,
I agree that I am liable to Now Health International for all claims settled for such medical Treatment in connection with any non-covered claim.
• I understand and confirm that where I have not repaid funds disbursed in good faith by Now Health International in respect of non-covered medical
Treatment, valid claims may be offset against outstanding funds due to Now Health International and/or my Plan may be suspended until the
outstanding amounts have been settled in full.
• I have consent from all my dependants covered under the Plan to administer additions and deletions and review claim payment reports on their behalf.
• I acknowledge that if it is determined by Now Health International that a claim was fraudulent my Plan may be terminated with immediate effect.
• I understand that if I am able to claim any costs from another insurance policy for the cost of any treatment or benefits received, Now Health International
will only be liable for a proportional share of the total costs.
• I have read the important notes.
• I agree to the declaration above and understand that cover is provided in accordance with the terms and conditions of the Now Health International Plan.

Signature (Insured/main applicant): Date (dd/mm/yyyy):

/ /

Signature & Name of Adviser: Date (dd/mm/yyyy):

/ / /

This plan is not a Medisave-approved plan and you may not use Medisave plan to pay the premium for this plan.
If you are a citizen or permanent resident of Singapore, you are covered by MediShield Life for life, for treatments in Singapore, regardless of pre-existing
medical conditions or other circumstances that you face. For more details on your coverage, please visit www.medishieldlife.sg.

Plan Owners’ Protection Scheme

This plan is protected under the Policy Owners’ Protection Scheme which is administered by the Singapore Deposit Insurance Corporation (SDIC).
Coverage for your plan is automatic and no further action is required from you. For more information on the types of benefits that are covered under
the scheme as well as the limits of coverage, where applicable, please contact your insurer or visit the General Insurance Association of
Singapore (GIA)/Life Insurance Association of Singapore (LIA) or SDIC websites (www.gia.org.sg or www.lia.org.sg or www.sdic.org.sg).

Now Health International (Singapore) Pte. Ltd.(No.201317502C) is a general insurance agent of Sompo Insurance Singapore Pte. Ltd.
and is registered with the Agents’ Registration Board of the General Insurance Association of Singapore (GIA).
Registered at 16 Raffles Quay #33-03 Hong Leong Building Singapore 048581.
Visit www.sompo.com.sg to find out more about Sompo Singapore.
SC SG 28004 2023 Page 8 of 8