INDIVIDUAL CREW SUBSCRIPTIONINDIVIDUAL PREMIUM 2020 OPTION 1 HEALTHCARE PLAN AGEPREMIUM/ YEAR (EUR/USD) STANDARD MLC16-35859 36-491,058 50-651,458 PERFECT 16-351,574 36-491,963 50-652,740 OPTION 2 DEATH & PERMANENT DISABILITY CAPITALPREMIUM / YEAR (EUR/USD) After Accident only 100.000183 200,000366 300,000549 400,000732 500,000915 PREMIUM / YEAR EUR (USD) After Any Causes (Accident+Illness) 100.000574 (660) 200,0001,147 (1,319) 300,0001,721 (1,979) 400,0002,294 (2,638) 500,0002,867 (3,297) OPTION 3 TEMPORAL TOTAL DISABILITY Any Causes AMOUNT/monthPREMIUM / YEAR EUR (USD) Benefits: maximum 80% on salary, waiting period 28 days2,000516 (593) 3,000774 (890) 4,0001031(1,186) 5,0001,289 (1,482) 6,0001,547 (1,779) 7,0001,804 (2,075) 8,0002,062 (2,371) OPTION 4 LEGAL ASSISTANCEPREMIUM/ YEAR (EUR/USD) FORMULA Seafarer 156 GENERAL CONDITIONS: HEALTHCARE PLAN (OPTION 1-2) TEMPORAL TOTAL DISABILITY (OPTION 3) LEGAL PROTECTION (OPTION 4) Please contact us if you have any questions regarding the form. We will be happy to assist you. 1 PARTICIPANT DETAILS2 PLAN OPTIONS 3 PAYMENT AND DURATION OPTION4 MEDICAL QUESTIONNAIRE & VALIDATION PARTICIPANTGender*MrMrsMsParticipant Name* Last Name First Name Date of Birth* Date Format: DD slash MM slash YYYY Use Calendar or fill the field "dd/mm/yyyy" with your Numeric KeypadMarital statusNationality*Function/Occupation*Captain, Engineer, Deckhand, Hostess,...Telephone*Email* enter your email confirm your email Address* Street Address Address Line 2 City ZIP / Postal Code AfghanistanAlbaniaAlgeriaAmerican SamoaAndorraAngolaAnguillaAntarcticaAntigua and BarbudaArgentinaArmeniaArubaAustraliaAustriaAzerbaijanBahamasBahrainBangladeshBarbadosBelarusBelgiumBelizeBeninBermudaBhutanBoliviaBonaire, Sint Eustatius and SabaBosnia and HerzegovinaBotswanaBouvet IslandBrazilBritish Indian Ocean TerritoryBrunei DarussalamBulgariaBurkina FasoBurundiCambodiaCameroonCanadaCape VerdeCayman IslandsCentral African RepublicChadChileChinaChristmas IslandCocos IslandsColombiaComorosCongo, Democratic Republic of theCongo, Republic of theCook IslandsCosta RicaCroatiaCubaCuraçaoCyprusCzech RepublicCôte d'IvoireDenmarkDjiboutiDominicaDominican RepublicEcuadorEgyptEl SalvadorEquatorial GuineaEritreaEstoniaEswatini (Swaziland)EthiopiaFalkland IslandsFaroe IslandsFijiFinlandFranceFrench GuianaFrench PolynesiaFrench Southern TerritoriesGabonGambiaGeorgiaGermanyGhanaGibraltarGreeceGreenlandGrenadaGuadeloupeGuamGuatemalaGuernseyGuineaGuinea-BissauGuyanaHaitiHeard and McDonald IslandsHoly SeeHondurasHong KongHungaryIcelandIndiaIndonesiaIranIraqIrelandIsle of ManIsraelItalyJamaicaJapanJerseyJordanKazakhstanKenyaKiribatiKuwaitKyrgyzstanLao People's Democratic RepublicLatviaLebanonLesothoLiberiaLibyaLiechtensteinLithuaniaLuxembourgMacauMacedoniaMadagascarMalawiMalaysiaMaldivesMaliMaltaMarshall IslandsMartiniqueMauritaniaMauritiusMayotteMexicoMicronesiaMoldovaMonacoMongoliaMontenegroMontserratMoroccoMozambiqueMyanmarNamibiaNauruNepalNetherlandsNew CaledoniaNew ZealandNicaraguaNigerNigeriaNiueNorfolk IslandNorth KoreaNorthern Mariana IslandsNorwayOmanPakistanPalauPalestine, State ofPanamaPapua New GuineaParaguayPeruPhilippinesPitcairnPolandPortugalPuerto RicoQatarRomaniaRussiaRwandaRéunionSaint BarthélemySaint HelenaSaint Kitts and NevisSaint LuciaSaint MartinSaint Pierre and MiquelonSaint Vincent and the GrenadinesSamoaSan MarinoSao Tome and PrincipeSaudi ArabiaSenegalSerbiaSeychellesSierra LeoneSingaporeSint MaartenSlovakiaSloveniaSolomon IslandsSomaliaSouth AfricaSouth GeorgiaSouth KoreaSouth SudanSpainSri LankaSudanSurinameSvalbard and Jan Mayen IslandsSwedenSwitzerlandSyriaTaiwanTajikistanTanzaniaThailandTimor-LesteTogoTokelauTongaTrinidad and TobagoTunisiaTurkeyTurkmenistanTurks and Caicos IslandsTuvaluUS Minor Outlying IslandsUgandaUkraineUnited Arab EmiratesUnited KingdomUnited StatesUruguayUzbekistanVanuatuVenezuelaVietnamVirgin Islands, BritishVirgin Islands, U.S.Wallis and FutunaWestern SaharaYemenZambiaZimbabweÅland Islands Country Currency for the Plan*EURUSDAll limits will be based on the currency chosenOPTION 1HEALTHCARE PLANPERFECT WORLDWIDE 1,514 (16-35 y/o) 1,890 (36-49 y/o) 2,637 (50-65+ y/o)STANDARD WORLDWIDE 826 (16-35 y/o) 1,020 (36-49 y/o) 1,404 (50-65+ y/o)None Premium / Year WCA membership, tax and fees included OPTION 2 ADEATH AND PERMANENT DISABILITY (Accident Only)100 000 (183/year)300 000 (549/year)500 000 (915/year)200 000 (366/year)400 000 (732/year)noneOPTION 2 BDEATH AND PERMANENT DISABILITY (Any Causes)100 000 (554/year)300 000 (1,662/year)500 000 (2,770/year)200 000 (1,108/year)400 000 (2,216/year)noneDEATH AND PERMANENT DISABILITY (Any Causes)100 000 (638/year)300 000 (1,912/year)500 000 (3,186/year)200 000 (1,275/year)400 000 (2,549/year)noneYou cannot subscribe option 2A and option 2B Please check "none" in 2B if you want only option 2A.BENEFICIARY DESIGNATION (in event of death)Spouse or in absence of, Born children or to be born, on equal partsOthersIndicate here : Name, date of birth, address and pourcentage for each beneficiary in case of deathOPTION 3TEMPORAL TOTAL DISABILITY (Any Causes)2 000 (498/year)4 000 (996/year)6 000 (1,494/year)3 000 (747/year)5 000 (1,245/year)8 000 (1,992/year)7 000 (1,743/year)none Amount (Premium/year)Cover : maximum 80% on salary. Waiting Period 28 days Work Contract required TEMPORAL TOTAL DISABILITY (Any Causes)2 000 (616/year)4 000 (1,233/year)6 000 (1,849/year)3 000 (925/year)5 000 (1,541/year)8 000 (2,465/year)7 000 (2,157/year)none Amount (Premium/year)Cover : maximum 80% on salary. Waiting Period 28 days Work Contract required OPTION 4LEGAL EXPENSESFormula Seafarer (156€)none SUBSCRIPTION DETAILSEffective Date of Coverage* DD MM YYYY For individual enrolment, the insurance contract start the first of each month to the due date 31/12. Periodicity (months)*3456123 months minimum. You are able to cancel the policy at any time by email. Any month started shall be due in full. 12 months= 1 year with automatic renewal FREQUENCY OF PAYMENT*Monthly (+8%)Quaterly (+4%)Half Yearly (+2%)Yearly(fees)FREQUENCY OF PAYMENT*Half Yearly (+2%)Yearly(fees)PAYMENT METHOD*Credit TransferDirect Debit (Sepa Area EUR only)Bank check (EUR only) Height (cm or Ft)*Weight (kg)*1. Are you currently on full or partial sick leave due to an illness or accident?*YesNoOver the past three years, have you ever been on sick leave for more than 30 consecutive days?*YesNo2. Are you currently under medical supervision (therapy, medical care) and/or are you taking prescribed medication (other than contraceptives)?*YesNo3. Are you entitled to military or civil disability pension of more than 15 percent?*YesNo4. Over the past 5 years, have any of your medical or viral tests yielded abnormal results?*YesNo5. Have you undergone surgery over the past 10 years or are you scheduled to do so in the future (exclusive of caesarean sections or appendectomies, or varicose veins, tonsils, adenoids or gallbladder removals).*YesNo6. Have you, over the past 10 years, been hospitalised in a hospital, clinic, health care facility or thermal cure institution or are you scheduled to do so in the next 12 months?*YesNo7. Over the past 10 years, have you ever suffered from an illness or condition that required medical supervision (therapy, medical care, medication) for more than 30 consecutive days?*YesNo8. Are you currently receiving dental care or are you scheduled to do so over the next 24 months?*YesNoIf you answered “yes” to any of these questions, please provide details below including dates, duration, specific medical grounds or reasons, carryover effects, therapy and results of tests:*Terms of Service*I declare that the answers given, whether in my handwriting or not, are true and complete to the best of my knowledge and belief, and will form the basis of the certificate of insurance for my application for the Plans. I understand that failure to disclose any material fact may invalidate the certificate of insurance. Note: A material fact is one which may influence the assessment or acceptance of your application for the Plans. If you are in any doubt as to the relevance of any information, please give details. Failure to disclose a material fact may invalidate your certificate of insurance resulting in the loss of your benefits. If I don’t have a Successor, I declare that any Benefits are payable to the WCA social Fund. I declare to have freely acted in my choice to indicate Association WCA asbl as unique beneficiary. I am perfectly aware of the statutes and the social works carried out by the Association. I agree to inform the FROLSON or Worldwide Crew Association a.s.b.l. (hereafter the company) in writing of any change in my circumstances between the date of this application and issue of the certificate of insurance. I also agree to inform the company of any change of name, change of address etc. that may occur during the life of the Plan. I consent to the company seeking independent verification (if considered necessary) of any of the information given in this application.Annual Taxes & WCA fees : 50 (€,$,£) If I don’t have a Successor, I declare that any Benefits are payable to the WCA social Fund. I declare to have freely acted in my choice to indicate Association WCA asbl as unique beneficiary. I am perfectly aware of the statutes and the social works carried out by the Association. Any disputes under the Plans shall be ruled only by courts located in Luxembourg. I acknowledge that I have read and unconditionally accept the GENERAL CONDITIONS for each Options chosen. I agree to the Terms of Service CAPTCHAPhoneThis field is for validation purposes and should be left unchanged.