EMERGANCY

HEALTH INSURANCE

This form can be emailed or submitted to us direct together with the required documents.

Address and telephone details DEFINITLY be provided for EMERGENCY.

Please fill this form with CAPITAL LETTERS by using a pen.

All sections of this form must be completed in Full. Failure to do so will result in delay or denial of
benefits.

Personal details

Title: Mr Mrs Miss

Middle
First Name:
name(s)
Surname:

Gender: Male Female

Date of D D M M Y Y Y Y
Birth: / /

Nationality: Passport No.

Phone No. E-mail:

Address:
HEALTH DECLARATION NOTICE AND AUTHORISATION
1. I agree, declare and undertake that the information given by me on this application form and attached documents about myself to be insured is
complete and accurate, that have not concealed anything which NORTHPRME NSURANCE LTD.
2. I declare that hereby authorize NORTHPRME NSURANCE LTD. to obtain information from any physician, healthcare institution and other insurance
companies on matters concerning the scope of my health insurance and to give information to Salk Sigortalar Bilgi ve Gzetim Merkezi (SAGMER)
[Health Insurance Information and Supervision Centre] on matters concerning the scope of my health insurance.
3. If the policy is issued and if, after having read the special and general conditions of the policy, don't send any objection of me about the policy to
NORTHPRME NSURANCE LTD. before making a claim under the policy and case at latest within 30 days following the inception date of the policy,
declare that have agreed all Special and General Conditions of the policy.
4. I have read, understood and agreed the information and Enlightenment Form which is an integral part of this
a pplication form .
5. I accept any notice required to be sent by NORTHPRME NSURANCE LTD. can be sent by mobile phone
message or e-mail.
6. I agree and declare that receipt of this application form by NORTHPRME NSURANCE LTD. does not commit NORTHPRME NSURANCE LTD. to execute
the insurance contract, that the application form/proposal must be delivered to NORTHPRME NSURANCE LTD. at latest within 5 days following the date
of completion thereof and that if this period is exceeded, my application will be rejected.

Documents required for application

 Photocopy of passport
 Recent Student Letter (valid up to 3 month)
 Health insurance payment bank receipt (50 Euro)

Policy holders/ Insured name and Surname Signature

DATE
/ / 2017

Please complete this form and return to: Near East University International Students Office, Ms. Malika Sadikova/Mrs. Verda
Gumush Ozatach. Alternatively, you can email the completed form, required documents and any queries to
malika.sadikova@neu.edu.tr or verda.ozatac@neu.edu.tr
HEALTH INSURANCE INFORMATION and ENLIGHTENMENT FORM
This form has been prepared based on the sample form proposed by the under secretariat of Treasure of the Prime Ministry of Turkey and contains general
information. For this reason, please carefully read the Special and General Conditions applicable to the product you have purchased.
Issued in minimum two counterparts , this form has been prepared pursuant to the Regulation on information in Insurance Contracts published on
28/10/2007 with the purpose of giving general information to the policy holder and other persons who will benefit from the insurance about their rights
and obligations both at the time of negotiation of the insurance contract and during the term of the insurance, about the subject and operation of the
contract and about any important changes and developments.
INFORMATION ABOUT THE INSURER
1. Information about the insurer who provided this
Trade Name : NORTHPME NSURANCE LTD.
Address : Nurullah Ata Sok. 41/1 KKLFTLK LEFKOA
Tel & Fax Num. : (0392) 228 7011 - (0392) 228 7211
B. CAUTION
1. In order to have more detailed information about this insurance, please carefully read the General Conditions of Health Insurance which will be the
insurer at your request, the Special Conditions of the List of Contracted Healthcare Institutions.
2. The application form completed by the policy holder/candidate insured person for the insurance Contract must have been completed in full, the answers
thereon answered corrected and must bear wed signature. Both the policy holder and the candidate insured person are obliged to declare to the insurer
anything known by them which must be known by the insurer. If this obligation is breached, the insurer may withdraw from the contract or keep the contract
in effect by applying such exclusions, limits and additional premium as it may deem fit. Therefore, you must refrain from giving incomplete or wrong
information to the insurer at any stage of the contract pursuant to the Article 6 of the General Conditions of Health Insurance.
3.Pursuant to the article 1431 of the Turkish Commercial Code, so long as the policy premium has not been paid, liability of the insurer will not comments.
4.Any change to the circumstances made after the execution of the contract without consent of the insurer which may affect the risk must be notified to the
insurer within eight days pursuant to the article 8 of the General Conditions of Health Insurance.
5. Unless otherwise agreed, the policy will commence at 12.00 hours and expire 12.00 hours at the dates of inception and expiry stated on the policy an in any
case upon occurrence of a risk.
C. GENERAL INFORMATION
1.The Insurer will indemnify the insured person(s) for expenses Incurred by them for diagnosis and treatment of any health condition of them resulting
from a disease or incidents occurred during the term of the policy specified on the policy or an endorsement up to the limit of the respective cover in excess
of the contribution of the Insured person specified on the corticated attached to the policy7endorsment in accordance with the provisions of the Turkish
Commercial Code, the General Conditions of Health Insurance and the special Conditions.
2. The Standard policy Premium is determined according to the age, gender, covers purchased, limits of covers, indemnity payment percentage,
geographic limit, chosen healthcare institutions, inflation of prices of healthcare services and Loss/Premium ratio of the health insurance portfolio of the
insurer. At the time of renewal of the policy, depending on the Loss/Premium ratio under the expired policy, no claim bonus or additional Premium specied in
the special conditions of the respective product will be applied. The Insured persons who have not earned the Lifelong Renewal Warranty will be subjected to a
risk assessment at the time of renewal of the policy and additional Premium, deductible and/or limit will be applied according to the result of the risk
assessment.
3.The Insurer may require medical examinations in order to assess the health risk of the insured person. The insurer reserves the right to reject an
application or accept it conditionally according to the health condition of the Insured person and/or as per the Risk Acceptance regulation of the Insurer.
4. The Insurer is entitled to request copies of the information and records about the health history of the insured person from all physician, healthcare
institutions and third persons who and which have provided medical treatment to the insured person before and after the term of the Insurance. If the insured
person declines to fill this request without a justifiable reason, the insurer may reject to pay indemnity or may terminate the contract.
5. The parties have the right to right to agree on such special conditions in addition to the general conditions of the Insurance, providing that they are not
contrary to the law and ethics and against the interest of the Insured person.
D.EXCLUSIONS
To have information about the events which are excluded from the coverage, please see the exclusions contained in the General Conditions of Health
Insurance and the Special Conditions of the Health Insurance Policy.
E. PAYMENT OF INDEMNITIES
1. In order to be able to claim their rights arising from the policy, the beneficiaries are obliged to furnish the required documents to the insurer. Documents
required for indemnity payment vary depending on the claim made under such cover provided buy the policy. Please make sure that the Information and
documents required for making of acclaim in respect of the expenses incurred at a Contracted or non Contracted Healthcare Intuition are availed in your policy
folder.
2. Claims will be assessed according to the Special Conditions of the purchased product, the General Conditions of Health Insurance and the limits of
coverage specified on the policy.
3. Upon occurrence of a risk, it is the insurer's obligation to pay indemnity.
F.OTHER INFORMATION
The Insurer is a member of the Arbitration System.
The Insurance Arbitration Commission has been established in accordance with the article 30 of the law No. 5684 with the purpose of settlement of the
disputes between the policy holders and the persons benefiting from the Insurance contract and the insurers being members of the Insurance Arbitration
System arising from the Insurance contract.
G.COMPLAINTS AND INFORMATION REQUESTS
1.You can apply to the address and telephone numbers given below to request information and file complaint on any matter concerning the insurance.
2. The insured person agrees that any information and communication concerning the insurance will be made via the communication data (including
sending of messages by mobile phone) given by the insured person at the time of issue of the policy.
3. If you don't receive the policy or the rejection letter within 30 days following the date of application, please call our Client Services at telephone number
(0392) 228 70 11