I declare that to the best of my knowledge and belief all statements that I have made in this application are true and correct whether they relate to me or my dependants (any other person /s whom I propose to insure being hereinafter referred to as Others), and that no material fact that can influence the acceptance or assessment of this insurance has been withheld. (If you are in any doubt as to whether a fact is material you must disclose it by contacting us on 21322600 or by email on [email protected]).

This declaration and the information given on this application shall be the basis of the contract between me/us and the Company (Atlas Insurance PCC Limited). If this form has been completed on my behalf by another person (including but not limited to any employees, agent or tied insurance intermediary of Atlas Healthcare Insurance Agency or an insurance broker) this person shall be my agent and not the agent of the company. I agree to read my/our membership agreement and be bound by the conditions of the said agreement unless I cancel my enrolment within 30 days of acceptance. I understand that if I am a third country national and requiring health insurance for visa purposes, the 30 day cooling off period will not apply and I will need to call at an office to collect the documentation.

I hereby warrant that I have explained this declaration and the document ‘Information to policyholders’ to Others and have obtained their explicit verbal consent.