INDIVIDUAL CREW SUBSCRIPTIONINDIVIDUAL PREMIUM 2018 OPTION 1 HEALTHCARE PLAN AGEPREMIUM/ YEAR (EUR/USD) STANDARD MLC16-35826 36-491,020 50-651,404 PERFECT 16-351,514 36-491,890 50-652,637 OPTION 2 DEATH & PERMANENT DISABILITY CAPITALPREMIUM / YEAR (EUR/USD) After Accident only 100.000183 200,000366 300,000549 400,000732 500,000915 After Any Causes (Accident+Illness) 100.000554 200,0001,108 300,0001,662 400,0002,216 500,0002,770 OPTION 3 TEMPORAL TOTAL DISABILITY Any Causes AMOUNT/monthPREMIUM / YEAR (EUR/USD) Benefits: maximum 80% on salary, waiting period 28 days2,000498 3,000747 4,000996 5,0001,245 6,0001,494 7,0001,743 8,0001,992 OPTION 4 LEGAL ASSISTANCEPREMIUM/ YEAR (EUR Only) 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 PARTICIPANT2 OPTIONS 3 PAYMENT OPTIONS PARTICIPANTGender*MrMrsMsParticipant Name* Last Name First Name Date of Birth* Use Calendar or fill the field "mm/dd/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 SamoaAndorraAngolaAntigua and BarbudaArgentinaArmeniaAustraliaAustriaAzerbaijanBahamasBahrainBangladeshBarbadosBelarusBelgiumBelizeBeninBermudaBhutanBoliviaBosnia and HerzegovinaBotswanaBrazilBruneiBulgariaBurkina FasoBurundiCambodiaCameroonCanadaCape VerdeCayman IslandsCentral African RepublicChadChileChinaColombiaComorosCongo, Democratic Republic of theCongo, Republic of theCosta RicaCôte d'IvoireCroatiaCubaCuraçaoCyprusCzech RepublicDenmarkDjiboutiDominicaDominican RepublicEast TimorEcuadorEgyptEl SalvadorEquatorial GuineaEritreaEstoniaEthiopiaFaroe IslandsFijiFinlandFranceFrench PolynesiaGabonGambiaGeorgiaGermanyGhanaGreeceGreenlandGrenadaGuamGuatemalaGuineaGuinea-BissauGuyanaHaitiHondurasHong KongHungaryIcelandIndiaIndonesiaIranIraqIrelandIsraelItalyJamaicaJapanJordanKazakhstanKenyaKiribatiNorth KoreaSouth KoreaKosovoKuwaitKyrgyzstanLaosLatviaLebanonLesothoLiberiaLibyaLiechtensteinLithuaniaLuxembourgMacedoniaMadagascarMalawiMalaysiaMaldivesMaliMaltaMarshall IslandsMauritaniaMauritiusMexicoMicronesiaMoldovaMonacoMongoliaMontenegroMoroccoMozambiqueMyanmarNamibiaNauruNepalNetherlandsNew ZealandNicaraguaNigerNigeriaNorthern Mariana IslandsNorwayOmanPakistanPalauPalestine, State ofPanamaPapua New GuineaParaguayPeruPhilippinesPolandPortugalPuerto RicoQatarRomaniaRussiaRwandaSaint Kitts and NevisSaint LuciaSaint Vincent and the GrenadinesSaint MartinSamoaSan MarinoSao Tome and PrincipeSaudi ArabiaSenegalSerbiaSeychellesSierra LeoneSingaporeSint MaartenSlovakiaSloveniaSolomon IslandsSomaliaSouth AfricaSpainSri LankaSudanSudan, SouthSurinameSwazilandSwedenSwitzerlandSyriaTaiwanTajikistanTanzaniaThailandTogoTongaTrinidad and TobagoTunisiaTurkeyTurkmenistanTuvaluUgandaUkraineUnited Arab EmiratesUnited KingdomUnited StatesUruguayUzbekistanVanuatuVatican CityVenezuelaVietnamVirgin Islands, BritishVirgin Islands, U.S.YemenZambiaZimbabwe Country OPTION 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 (554year)300 000 (1,662/year)500 000 (2,770/year)200 000 (1,108/year)400 000 (2,216/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 (472/year)4 000 (943/year)6 000 (1,415/year)3 000 (708/year)5 000 (1,179/year)8 000 (1,887/year)7 000 (1,6516/year)none Amount (Premium/year)Cover : maximum 80% on salary. Waiting Period 28 days Work Contract required OPTION 4LEGALE EXPENSEFormula Seafarer (156€)noneEUR only----Price/year----Yearly enrolment only 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 Currency*EURUSDGBPFREQUENCY OF PAYMENT*Monthly (+8%)Quaterly (+4%)Half Yearly (+2%)Yearly(fees)PAYMENT METHOD*Credit TransferDirect Debit (Sepa Area EUR only)Bank check (EUR only)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 CAPTCHANameThis field is for validation purposes and should be left unchanged. This iframe contains the logic required to handle Ajax powered Gravity Forms.