TUI Group Healthcare Trust
Registration/Amendment form
(Delete as applicable)
Please complete this form in block capitals and return it to your Payroll Administrator.
1
Employee (lead member) details
1.1 Your title and name:
Mr
Other:
Mrs
Ms
Miss
First name:
Surname:
1.2 Your postal address:
Postcode:
1.3 Date of birth:
D
D
M
M
Y
Y
1.4 Employee number:
1.5 National Insurance number:
1.6 Home telephone number:
1.7 Business telephone number:
AXA PPP healthcare Administration Services Limited, Phillips House, Crescent Road, Tunbridge Wells, Kent TN1 2PL.
Registered Office: 5 Old Broad Street, London EC2N 1AD, United Kingdom. Registered in England No. 3429917. ©AXA PPP healthcare 2016.
In order to maintain a quality service, telephone calls may be monitored or recorded.
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PB55820a/04.16
1.8 Email:
2
Details of family members (to be included on your plan)
2.1 First names of family members to be included (eldest first) – children to be under 21 or 25 if in full-time
education (Include surname if different from above).
Title:
First name:
Relationship to lead member:
Surname:
Date of birth:
D
Title:
First name:
Relationship to lead member:
First name:
Relationship to lead member:
First name:
Relationship to lead member:
First name:
Relationship to lead member:
Y
Male
Female
D
M
Gender:
M
Y
Y
Date of birth:
Male
Female
D
M
Gender:
M
Y
Y
Male
Female
Surname:
Date of birth:
D
M
Gender:
M
Y
Y
M
Y
Y
Male
Female
Surname:
Date of birth:
D
3
Y
Surname:
D
Title:
Gender:
M
Date of birth:
D
Title:
M
Surname:
D
Title:
D
D
M
Gender:
Male
Female
Data Protection Act
Please make sure that you either show this statement to any family member covered by this healthcare scheme, or
inform them of its contents before you return this form.
To set up and administer your healthcare scheme membership AXA PPP healthcare Administration Services limited
will hold and use information about you and any family members covered by the healthcare scheme, supplied by
you, those family members, medical providers or your employer. Please ensure that you only provide us with
sensitive personal information, such as health information, about other people with their agreement. When you give
us this information we will take this as confirmation that you have consent to do so.
We send personal and sensitive personal information in confidence for processing by other companies and
intermediaries including those located in countries outside the European Economic Area (EEA) including to countries
where the laws protecting personal information may not be as strong as in the EEA. We take steps to ensure that
any sub-contractors give at least the same protections as we do. We may share details of the value and types of
claims with the sponsoring employer, any scheme trustees and any intermediaries they authorise, whilst respecting
every person’s right to medical confidentiality. This is to enable them to assess the value and effectiveness of the
healthcare scheme and our services.
We send correspondence about healthcare scheme membership, including claims correspondence to the eligible
employee. If any person that you intend to include under the scheme does not want us to do this you should not
include them.
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By signing and returning this form you indicate that you have authority to give consent on behalf of any family
members covered by the healthcare scheme and on your own and their behalf you consent to the use of personal
information in the ways described above.
We are required by law, in certain circumstances, to disclose information to law enforcement agencies about
suspicions of fraud and other crime. We will disclose information to third parties for the purposes of prevention or
investigation of crime including reasonable suspicion about fraud or otherwise improper claims. This may involve
adding non-medical information to a database that will be accessible by other insurers and healthcare scheme
administrators as well as law enforcement agencies. We are obliged to notify the General Medical Council or other
relevant regulatory body about any issue where we have reason to believe a medical provider’s fitness to practice
may be impaired.
By signing and returning this form you agree that we, and other members of the AXA UK Group, may use the
information you have provided to inform you by letter, telephone, email or mobile message of products and services,
such as special offers and healthcare information unless you tick this box to indicate otherwise .
You may change your mind at any time by writing to the address on the back of the Membership Handbook.
4
Declaration
Please note: If any of the information you have given us changes before we have told you that your healthcare
scheme has begun, you must tell us in writing at once. We advise you to keep a record of all information you give us
in connection with this application, including any letter(s) you send us in connection with it.
If you would like a copy of this application, please let us know within three months. We may turn down an application
if we discover that the information you give us is not sufficiently true, accurate and complete so as to enable us fairly
to assess the risk we are taking on.
4.1 I declare that to the best of my knowledge and belief the statements on this form are full, true and correct. I
acknowledge that the acceptance of my application shall be on the basis of these statements and that I and any
family members included in my plan shall be bound by the handbook terms and benefits table. I acknowledge that
if an intermediary is acting on my behalf they have no authority to act on behalf of AXA PPP healthcare.
Please note: If you don’t take reasonable care and the information you give us is inaccurate or incomplete then
we may take one or more of the following actions:
(i) Cancel your plan;
(ii) Declare your membership void (treating your plan as if it had never existed);
(iii) Change the terms of your plan; or
(iv) Refuse to deal with all or part of any claim or reduce the amount of any claim payments.
We may ask you to provide further information and/or documentation to make sure that the information you gave
us when taking out, making changes to or renewing your plan was accurate and complete.
Lead member’s
signature:

Date:
D
D
M
M
Y
Y
After completing this application, including the above declaration, please return it to your Payroll
Administrator.
To be completed by your Payroll Administrator when the company is to pay the employee’s part of the subscription. The above
employee is/will be eligible for inclusion in the group arrangement on________________ (This is the date on which the cover
will take effect).
Signature
of Payroll
Administrator:

Date:
D
D
M
M
Y
Y
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