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Health Cash Back Plan :: KlaptonOnline
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Health Cash Back Plan Application Form
Note: * Indicates required field.

Applicant Information

List of insured persons (to add additional persons to your cover click add)

Acknowledgement and Declarations

I authorise any medical practitioner, or any other person(s) concerned with providing healthcare, to provide Klapton Cash Back Plan with any information that may be relevant to this Cash Back Plan Cover.

If submitting any information on behalf of another person covered by my policy, I also confirm that I am doing so with their knowledge and permission.

I declare the information shown on this form and any accompanying documentation is true and complete.

I hereby confirm that I have read and agree with the above statement.

I, the undersigned declare that all answers in this application form are complete and accurate. I understand completely that the answers provided are the basis for the provision of Insurance Cover. Furthermore, I declare that I do not have any supplementary information, in respect of this application, which could influence the outcome of your decision regarding my application request. My signature warrants that my application is submitted in all good faith.

I hereby confirm that I have read and agree with the above statement and it applies both to me and to any additional professional/practitioner and administrative employee included in this application.

Premium Payment Information: I hereby confirm that I understand that after completing and submitting this application form, I must pay the required premium before any cover will become effective.

Submitted Date: 16 Sep 2019