INTERNATIONAL SCIENCE
APLLICATION FORM
HEALTHCARE PLAN
* = compulsory

Application at Foyer Global Health and at ERGO Insurance Group
Insured Persons *
(Please complete the following details for all persons to be insured)


Family Name First Name Date of Birth Gender
Scholarship
holder*

Spouse
Child
Child
Child
Optional Maternity Care benefit *   
from until (YY.MM.DD)

Declaration: I acknowledge that all pre-existing conditions as defined in the exclusions are not covered. I confirm that the details made in this application describe the basis of the contract between the policyholder and the insurer. The terms and conditions will be made available to me together with the Policy Documentation. I accept these Terms and Conditions to be part of contract of insurance issued as a result of this Application.

I authorise the release of any medical information to the Insurer or to the Claims Service acting on behalf of the Insurer as is required to settle all eligible benefits to me, my spouse or children for this claim. A copy of this authorisation shall be considered as effective and valid as the original.

Signature of Scholarshipholder


Date:

Tel. +(49) 4152 839 404 , Fax +(49) 40 3296 3117, Email: Antrag@ihcc.de
You can find the special terms and conditions in the download section