APPLICATION FORM FOR GROUP HEALTH INSURANCE

Policy Type: Group Health Complementary Group Health

Employee Registration Number: Task: Firm Name:
Please fill the form with capital letters and as readable. Your identity information should be same as the information on
your identity card. If your family members to be insured are more than five persons, please fill a second form.
Insuree candidate’s name Nationality R.T. Identity No. Place of Birth Date of Birth Sex Father’s Marital Height/ For Are
women:
you
and surname Name Status Weight pregnant?
Employee: ..../..../........ M F M S .....cm/.....kg Y N
Spouse: ..../..../........ M F M S .....cm/.....kg Y N
1st child: ..../..../........ M F M S .....cm/.....kg Y N
2nd child: ..../..../........ M F M S .....cm/.....kg Y N
3rd child: ..../..../........ M F M S .....cm/.....kg Y N
(*): For foreign citizens, foreign identity card number and/or tax identity number is/are specified.
Contact Information: For notifications to the insurees, the employee’s CONTACT INFORMATION is also valid for the
employee’s family and if there are notifications to the employees, they are considered as made to other family members in
the policy. In case it is forwarded collectively by the Policy Owner, it expresses the employee’s office address, mobile phone
number and e-mail address and in case it is not forwarded, it expresses the policy owner’s office address, mobile phone
number and e-mail address.
Province District Quarter
Town Street Alley
Site Apt. Block/Apt. No.
Door No. Flat No. Postal Code
Home (0..........)...................... Office Tel No. (0..........)...................... Mobile Phone No. (0..........)......................
Tel No.
Office e-mail Other e-mails
Insured employee’s bank account information for the indemnity payments:
IBAN No. T R
If it is a joint account, the account holders’ names:
Social Security Number:
Are you insured in scope of SGK? Y N If yes,
If until now you have a private health and/or life insurance and/or
a rejected application at our company or another insurance company,
please write the company name and its period.
HEALTH DECLARATION (Please declare by selecting diseases from the Disease Group list)
Is there any operation, disease/disorder which were underwent previously or any disease/disorder which is continuing
its follow-up and treatment or any health complaint which was not applied to a physician for the persons to be insured
(employee and their dependants)?
No, If yes, please mark from following health groups.
In case the health group is not in the list, please specify details by using “other” [Link] enclose the reports
(physician reports, pathology, epicrisis reports, diagnosis results, etc.) related to the disease group marked.
 1. Lung / Respiratory Tract Diseases  2. Intestinal diseases
 3. Nose, Head, Sinus, Concha Diseases  4. Dermatologic and/or Lymphatic Gland Diseases
 5. Joint Diseases (Knee, Hip, Shoulder, etc.)  6. Eye Diseases
 7. Benign cyst, bulk/tumor  8. Blood Diseases
 9. Endocrine System Disease (such as Hormonal Diseases)  10. Muscular, Bone Diseases (including Fractures and dislocations)
 11. Breast Diseases  12. Prostate and Testis Disease
 13. Uterus and Ovary Diseases  14. Nervous System, Brain/Cerebrovascular Diseases
 15. High Blood Pressure  16. Varicose vein
 17. Anorectal Disorders (such as Hemorrhoid, Fistula)  18. Kidney and Urinary Tract Disorders
 19. Growth and Developmental Delay  20. Congenital, Genetic Diseases
 21. Hernia (such as Inguinal, Umbilical Hernia)  22. All kind of cancer, malignant characterized tumors
 23. Cardiovascular Diseases  24. Ear-Balance Disorders
 25. Liver, Gall, Pancreas, Spleen Diseases  26. Diabetes, Insulin Resistance, Glucose Metabolism Disorders
 27. Spinal Diseases (Neck, Back, Waist)  28. Psychiatric Diseases
 29. Rheumatic Diseases  30. Oesophagus, Stomach, Duodenum Diseases
 31. Thyroid and Parathyroid Gland Diseases  32. Other,_____________________________
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Please explain the details below by specifying the disease group number above-marked according to the insuree candidates.
Name-Surname No: Disease Date of Diagnosis Method of Treatment Date of Treatment Examination Actual Situation

DECLARATION AND COMMITMENT

I hereby accept, declare and undertake in advance following articles for me and my family members who I want to be insured
in accordance with this Application Form which consisting 2 pages which I have filled completely by accepting the insurance
conditions.
Assessment of the Application:
I accept, declare and undertake that Allianz Sigorta A.Ş. (Allianz) did not make a commitment upon the Form was filled by
me; the information and documents forwarded by the Form, the policy scope and content will be assessed and its validity will
be determined in frame of the Policy Special Conditions and if any, the Protocol, the Health Insurance General Conditions,
the risk assessment principles of Allianz; it may do any transaction without the information and documents from companies
which I had made insurance policies previously; in this scope, Allianz reserves its rights for changing the policy premiums,
applying exception and/or extra disease premium or not accepting the application;
Full, Correct and Complete Information:
All information above-mentioned is full, correct and complete; there is no any information which I hesitate to share by
considering as unimportant; I do not hide any situation which it must be known by Allianz; I know any diseases/disorders
which are current on the signature date of the Form and/or previous diseases/disorders will not be included in the coverage
and I accept it; in case there are questions which not marked on the Form, answer of this question will be considered as
“no”; I know that in case there is any deficient and fault data on the Form and/or in the process of assessment of the
application or before it, because of the diseases/disorders determined from information and documents from previous
insurance company, Allianz have rights to not issue a policy on behalf of me, if a policy is issued, to not pay any indemnify
or to give up the insurance under the Turkish Commercial Code, Policy Special and General Conditions; in case there
is any deficient data on the Form and/or additional examination is requested by Allianz, after the requested documents
arrive to Allianz and are assessed by it, it will be determined whether I will include in the policy;
Sharing of Information:
I authorize Allianz to provide and share data and documents by examining at R.T Prime Ministry Treasury Undersecretariat,
Health Insurance Information and Observation Center (SBGM), Insurance Union of Turkey (Insurance Reinsurance and
Pension Companies Union of Turkey), all health corporations and institutions in frame of relevant legal regulations including
insurance legislation, relevant regulations, health legislation; therefore I will not claim against the company and private
and public health institutions, physicians and other relevant corporations which share my health information and I will not
make any legal and penal attempt against such corporations;
Communication Permits:
I agree that my personal information forwarded in scope of the contract/policy to be issued by and provided by Allianz
Sigorta A.Ş. from relevant persons and corporations may be used in order to give general information, benefit from
suitable products, improvement, advantage or campaigns in accordance with my requirements and to provide all kind
of information to me and my personal information may be shared by Allianz Sigorta A.Ş. with Allianz Hayat ve Emeklilik
A.Ş., Allianz Yaşam ve Emeklilik A.Ş. and their agencies and agencies and contracted business partners of Allianz
Sigorta A.Ş. in accordance with it; visual and voice messages, presentation and marketing posts can be forwarded
to me by Allianz Sigorta A.Ş., Allianz Hayat ve Emeklilik A.Ş. and Allianz Yaşam ve Emeklilik A.Ş. and their agencies
directly or through MMS, telephone, fax, automatic calling machines, electronic mail and similar communication
channels containing SMS, photo, animation, short message, multimedia objects; I know I have right to object to all
data, voice, visual, etc. messages completely or according to products or channel when I want. 
Right of Objection:
I accept, declare and undertake that I know that the policy with all Special and General Conditions will ensure about me
if I do not object to Allianz within maximum 30 days as from the issued.

Declaration Holder’s (*):

10.2015/1.000 Adet

Name-Surname: Date of Form Declaration): Signature

(Declaration Holder)

(*) One of 18 age and above insuree candidates or under 18 age insuree candidate’s parents)
Allianz Sigorta A.Ş.
Allianz Tower Küçükbakkalköy Mah. Kayışdağı Cad. No:1 34750 Ataşehir/İstanbul Phone: (0216) 556 66 66 Fax: (0216) 556 67 77
Registration No: 6022 Allianz Solution Line 444 45 46 Mersis No: 0-8000-0132-7000012 [Link]
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