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does the application form collect for the policyholder and dependants?","Question",{"text":109,"@type":110},"It collects personal and contact details such as name, gender, date of birth, relationship to the policyholder, occupation, residence, email address, telephone number, and identification information.","Answer",{"name":112,"@type":107,"acceptedAnswer":113},"How can the applicant choose the plan coverage?",{"text":114,"@type":110},"The form provides an enrolled plan section where coverage benefits such as hospitalization, outpatient, dental, and maternity can be selected (e.g., Diamond/Gold/Silver/Bronze tiers).",{"name":116,"@type":107,"acceptedAnswer":117},"What is required when a medical questionnaire answer is “YES” ?",{"text":118,"@type":110},"For any question answered ✓ YES, complete details must be provided, including the medical condition in the text box and full information about attending physicians, diagnosis, treatment dates and types, prognosis, and current course of 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trả lời tất cả các câu hỏi dưới đây bằng cách viết hoặc đánh dấu vào 􀂅 nơi tương ứng  \n􀂅 New Application 􀂅 Change 􀂅 Renewal  \nHợp đồng mới Thay đổi Tái tục  \nPart I – PERSONAL INFORMATION/ Phần I – THÔNG TIN CÁ NHÂN  \n\n| Policyholder Chủ hợp đồng |  |  |  |  | Job title/Occupation\u003Cbr>Nghề nghiệp/Chức vụ công tác |  |  |  | Telephone No Điện thoại số |  |  |  |  |\n| --- | --- | --- | --- | --- | --- | --- | --- | --- | --- | --- | --- | --- | --- |\n| Email Address Địa chỉ email |  |  |  |  | Contact Address Địa chỉ liên hệ |  |  |  |  |  |  |  |  |\n| Personal details Thông tin cá nhân |  | Policyholder\u003Cbr>Chủ hợp đồng |  |  |  | Dependant 1 Người phụ thuộc 1 |  | Dependant 2 Người phụ thuộc 2 |  |  |  | Dependant 3 Người phụ thuộc 3 |  |\n| Name Tên |  |  |  |  |  |  |  |  |  |  |  |  |  |\n| Gender\u003Cbr>Giới tính |  | Male\u003Cbr>Nam |  | Female Nữ |  | Male\u003Cbr>Nam | Female Nữ | Male\u003Cbr>Nam |  | Female Nữ |  | Male\u003Cbr>Nam | Female Nữ |\n| Date of Birth Ngày sinh (dd/mm/yyyy) |  |  |  |  |  |  |  |  |  |  |  |  |  |\n| Relationship with Policyholder/ Quan hệ với chủ hợp đồng |  |  |  |  |  |  |  |  |  |  |  |  |  |\n| Occupation\u003Cbr>Nghề nghiệp |  |  |  |  |  |  |  |  |  |  |  |  |  |\n| Country of Residence Nước thường trú |  |  |  |  |  |  |  |  |  |  |  |  |  |\n| Country\u003Cbr>Quê quán |  |  |  |  |  |  |  |  |  |  |  |  |  |\n| Height (cm)\u003Cbr>Chiều cao | Weight (kg)\u003Cbr>Cân nặng |  |  |  |  |  |  |  |  |  |  |  |  |\n| Passport/ID. No\u003Cbr>CMND/CCCD/Hộ chiếu |  |  |  |  |  |  |  |  |  |  |  |  |  |\n| PLAN ENROLLED CHƯƠNG\u003Cbr>TRÌNH LỰA CHỌN |  |  |  |  |  |  |  |  |  |  |  |  |  |\n| Hospitalization benefit Quyền lợi nằm viện |  |  | Outpatient benefit Điều trị ngoại trú |  |  |  | Dental benefit Chăm sóc nha khoa |  |  |  | Maternity benefit Thai sản |  |  |\n| Diamond |  |  | Outpatient 4\u003Cbr>Ngoại trú 4 |  |  |  |  |  |  |  |  |  |  |\n| Gold |  |  | Outpatient 3\u003Cbr>Ngoại trú 3 |  |  |  |  |  |  |  |  |  |  |\n| Silver |  |  | Outpatient 2\u003Cbr>Ngoại trú 2 |  |  |  |  |  |  |  |  |  |  |\n| Bronze |  |  | Outpatient 1\u003Cbr>Ngoại trú 1 |  |  |  |  |  |  |  |  |  |  |\n\nUW-HIE-P-001-01-B  \nLiberty MediCare – Application Form – Individual Policy  \nLiberty MediCare – Giấy yêu cầu bảo hiểm – Hợp đồng Cá nhân  \nThe Company shall not provide cover and shall not be liable to pay any claim or provide any benefit hereunder to the extent that the provision of such cover, payment of such claim or provision of such benefit would expose the Company to any sanction, prohibition or restriction under United Nations resolutions or the trade or economic sanctions, laws or regulations of the European Union, United Kingdom or United State of America.  \nCông ty sẽ không bảo hiểm và không có trách nhiệm thanh toán bồi thường cho bất kỳ yêu cầu bồi thường hoặc cung cấpcác quyền lợi nào nếu như việc việc cung cấp bảo hiểm, thanh toán các yêu cầu bồi thường này hoặc cung cấp quyền lợinhư vậy sẽ làm cho Công ty vi phạm bất kỳ quy định cấm vận, ngăn cấm, hoặc hạn chế theo các nghị quyết của Liên Hiệp Quốc hoặc các lệnh cấm vận kinh tế hay thương mại, luật pháp hoặc quy định của Liên Hiệp Châu Âu, Vương Quốc Anh hoặc Hiệp Chủng Quốc Hoa Kỳ .  \n\n| Annual Premium Phí bảo hiểm năm | Requested Effective Date Ngày hiệu lực yêu cầu | From Từ | To Đến |\n| --- | --- | --- | --- |\n| Loading Tăng phí | Payment method\u003Cbr>Phương thức thanh toán\u003Cbr>􀂅 Cash Tiền mặt | 􀂅 Cheque Séc | 􀂅 Bank Transfer Chuyển khoản |\n| Discount Giảm phí |  |  |  |\n| Total\u003Cbr>Tổng cộng\u003Cbr>0 | Please note bank charges for remittance will be borne by remitter, please fax or email the bank remittance advice or instruction for reference.\u003Cbr>Xin lưu ý người chuyển tiền sẽ chịu phí chuyển tiền qua ngân hàng, đề nghị gởi giấy chuyển tiền qua fax hoặc email cho Công ty Bảo hiểm tham chiếu. |  |  |\n\nPART II (A)– MEDICAL QUESTIONNAIRE/ PHẦN II (A)– CÂU HỎI ","cbCailtXBcjgIiSu","https://ap.wps.com/l/cbCailtXBcjgIiSu","pdf",560091,"English","# Part I - PERSONAL INFORMATION\n# PLAN ENROLLED\n# PART II (A) - MEDICAL QUESTIONNAIRE","[{\"question\":\"What does the application form collect for the policyholder and dependants?\",\"answer\":\"It collects personal and contact details such as name, gender, date of birth, relationship to the policyholder, occupation, residence, email address, telephone number, and identification information.\"},{\"question\":\"How can the applicant choose the plan coverage?\",\"answer\":\"The form provides an enrolled plan section where coverage benefits such as hospitalization, outpatient, dental, and maternity can be selected (e.g., Diamond/Gold/Silver/Bronze tiers).\"},{\"question\":\"What is required when a medical questionnaire answer is “YES” ?\",\"answer\":\"For any question answered ✓ YES, complete details must be provided, including the medical condition in the text box and full information about attending physicians, diagnosis, treatment dates and types, prognosis, and current course of treatment.\"}]","MediCare Application Form - Individual | PDF",1789823134]