I hereby apply for Clover Plan - NESACARD membership with MediSky International, insured with LAMP Insurance Company Limited. I confirm that I have not seen a doctor or other healthcare professional or have been admitted to hospital, received treatment or undergone any investigations in the last three years for any cancer related condition. I confirm that I have not experienced any signs and symptoms of any medical problem in the last 6 months regardless of whether a healthcare professional has been consulted. I accept the benefits terms conditions and limits provided for in the terms of the insurance policy and I agree to be bound by such terms. I confirm the correctness of the statements and information contained in this application and confirm the correctness of all other documents submitted now or in the future concerning this application. We accept that LAMP Insurance Company Limited will be relying on such statements and information when agreeing to accept this application. LAMP Insurance Company Limited reserves the right to investigate where uncertainty exists about the validity of information provided.
I, the applicant, agrees to being called upon to submit such medical examinations and tests as LAMP Insurance Company Limited deems necessary.
I agree to give LAMP Insurance Company Limited immediate written notice should any changes material to the assessment of this application occur before the date upon which LAMP Insurance Company Limited grants written acceptance. This will give LAMP Insurance Company Limited the opportunity to reconsider the terms of acceptance.
CONSENT FOR PERSONAL DATA PROCESSING OF THE MAIN MEMBER / POLICYHOLDER
I, the undersigned, pursuant to Art. 23 paragraph 1 point 1 and art. 27 paragraph 2 point 1 of the Personal Data Protection Act of 29 August 1997 (hereinafter the "Data Protection Act"), express my consent to the processing of my personal data, including my health status, in order to process my application for insurance cover and to execute insurance contracts concluded on this basis.
I declare that I have been informed about the right to access the content of my data, to correct it and to request in written form to cease my data processing as well as to object to its processing. In case of a breach of the provisions on personal data protection I have the right to submit a complaint with the Inspector General for the Protection of Personal Data (GIODO).
The above consent, pursuant to Art. 23 paragraph 2 of the Data Protection Act is also expressed for the future.
We kindly inform you that your personal data will be processed by MEDISKY sp. z o.o. with its registered office in Warsaw, 00-074 ul. Trębacka 4, registered in the register of entrepreneurs of the National Court Register under KRS number: 628122, on the basis of entrusting the processing of such data, pursuant to art. 31 of the Data Protection Act, by the data controller - ie LAMP Insurance Company Limited based in Gibraltar (GX11 1AA) Suite 934 Europort.
We inform that the data submission is voluntary but necessary to present an insurance offer and to conclude insurance contract, which includes insurance risk assessment.
We would like to inform you that your personal data will be processed for the purposes of identifying the application for insurance coverage, the conclusion of an insurance contract and insurance cover.
We inform you that if your insurance contract is concluded, your personal data will be processed for the purpose of performing it, and in the event of refusal to be covered by insurance, it will only be processed for archival purposes.
We would like to inform you that your application for change of personal data, contact information, request for discontinuation of data processing or objection must be sent to the following e-mail address: firstname.lastname@example.org.
I, the undersigned, declare that the information supplied is accurate and up-to-date and I have completed the application myself. I declare that I have received the General Terms and Conditions (Policy Wording) of NESACARD insurance and I have read it