AXA iHealthy Application — Online Form

Section 1 | Personal information of the insured

Name

Gender

Male Female

Surname

Date of Birth

Phone (thai)

+66

Email Address

Family Status

Passport Number

If married, since when?

How many children

Occupation

Nationality

Last occupation (if retired)

Highest Qualification

Annual Income

Current residential address

Workplace Address (If any)

Last address in Home Country

Section 2 | Insurance Plan Selection

Deductible

Yes No Do you want to add the deductible to lower the premium?

A deductible is the fixed amount you must pay yourself before your insurance starts covering costs.

Start Date

Section 3 | Payment

Payment Frequency

annual semi-annual monthly

Monthly payments are available only under the following conditions:

Payment of the first two months' premiums upfront
Holding an active account with one of the following banks:

Krungsri, Krungthai, SCB, Bangkok Bank

Section 4 | Beneficiary (MANDATORY)

If the beneficiary is a minor (under 15), the applicant must appoint a legal guardian.

Name

Gender

Male Female

Surname

Date of Birth

Nationality

Relationship to the applicant

ID or Document Number

Section 5 | Insured's Health

Height (cm)

Weight (kg)

Change in weight over the past 6 months:

Increased Decreased No significant change

If yes, please specify reason:

If there is any additional information the insured or policyholder would like to declare

Section 6 | Compliance with Anti-Money Laundering Law

I confirm that the premium payment is not associated with money laundering or any illegal activity.

The information provided is accurate and up to date.

Yes No I am not a U.S. citizen or resident as defined under FATCA

U.S. Status

a. Are you a U.S. citizen or resident? YesNo

b. Do you have a U.S. permanent resident card (Green Card)? YesNo

c. Have you ever declared tax residency in the U.S.? YesNo

d. Are you a US tax resident? (e.g., present in the USA for at least 183 days in the previous calendar year) YesNo

Section 7 – Declarations, Consents, and Confirmations

1. I certify that all answers and information provided in this application are true…
2. I authorize any hospital, clinic…
3. I understand and accept…
4. I confirm that I have read…
5. I authorize the company to collect…
6. … OIC …

(1) Disclosure of personal data to OIC…
(2) Disclosure for statistical…
(3) Sharing of data…
(4) Disclosure for the promotion…

Section 8 – Important Notices

1. In case of policy cancellation…
2. Before signing…
3. The insurer may contact you…
4. If the health declaration…
5. The applicant has the right…

Confirmation: I have read and understood this document including the privacy policy and give consent to all relevant conditions.

Signature & Confirmation

Date

Signature (Applicant)

Signature (Legal Guardian / Authorized Representative)

Signature (Witness, if any)

additional documents are requested from Foreigners:

1. All passport pages with stamps and Visa (Visa History is required)
2. All work permit pages (if any)
3. Driver's license (Without a valid driver's license, no coverage applies to vehicle-related claims)
4. Proof of actual address (housebook or rental aggreement)
5. ID or Passport Copy of the Beneficiary
6. Picture of your Bankbook (in case of monthly payment)

The translations serve as an aid only. The English original version is authoritative for the application; the generated PDF is created in English.

After sending you will receive a reference number…