Individual subscription

I declare that:
 that I have received and read the information booklet for the health insurance contract underwritten by WCA.
 I have provided all the information requested in a complete, sincere and accurate manner; and I acknowledge that this questionnaire must be completed by each person to be insured; and that all answers to the questions are compulsory.
 I am aware that, in accordance with Article L.113-8 of the Insurance Code, independently of the ordinary causes of nullity and subject to the provisions of Article L.132-26 of the Insurance Code, the cover granted to the Member by the Insurer is null and void in the event of concealment or intentional misrepresentation by the Member both at the time of subscription and during the course of the contract, when this concealment or misrepresentation changes the object of the risk or reduces the Insurer’s opinion of it, even though the risk omitted or misrepresented by the Member has had no influence on the realisation of the risk;
 I am aware that in the event of a claim or any application for assistance, the conscious and voluntary production of inaccurate or fraudulent documents will result in the forfeiture of cover without reimbursement of the contributions already paid;
 I reside and work outside the borders of the country of which I am a national.
 I will report any change to my family members within fifteen (15) days of becoming aware of the change.

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.