Apply for Travel Medical Insurance

Membership Number

1. Please Fill In Your Personal Details

Ensure to write your names as they appear on your passport
Note that the maximum number of travel days covered per dependant is 90 day per annum/year
Maximum age limit for travel insurance cover is 80 years old

2. Please Indicate Your Health Plan

Health Plans

Access

Comprehensive

Executive

Prestige

Level of Cover

Core

Plus

Extra

Max

Section A: Principal Members Details

Title

First name (s)

Surname

Date of Birth

Email Address

Passport No

Section B: Travel Details

Date of Departure

Date of Return

Departure Country

Destination Country

Section C: Travelling Dependants Details

Re-order	Title	First names (s)	Surname	Date of Birth	Passport No	Weight	Operations
	Title	First names (s)	Surname	Date of Birth	Passport No	Item weight

more items

Please fill out this form if you intend to seek medical services while out Botswana

NOTE:
All emergency medical services accessed while travelling outside Botswana will be covered by the Travel Insurance. Please refer to your travel insurance policy document for more information how to submit those claims. You may fill out this form and email it to bomaid@bomaid.co.bw before you access non-emergency medical services while outside Botswana The following are services for which pre-authorisation must first be sought before treatment: Hospitalization, Specialized radiology (CT, MRI, Nuclear medicine, PET scans), Appliances, Chemotherapy and Radiation therapy, Renal dialysis, Specialised dentistry, Orthodontic treatment. Requests for pre- authorisations must be emailed to casemanagement@bomaid.co.bw

Member Declaration

Re-order	Patient Name	Membership No.	Type of service e.g maternity delivery/ dental services / optical services	Expected Date of service	Country of sevice	Weight	Operations
	Patient Name	Membership No.	Type of service e.g maternity delivery/ dental services / optical services	Expected Date of service	Country of sevice	Item weight

more items

Name Of Principal Member

Membership Number

CLIENT INFORMATION CONSENT

In terms of the Data Protection Act, Bomaid is obligated to obtain the customer’s consent to acquire and process customer information. To provide performance of a contract to which the customer is a party, Bomaid might have to share the customer’s personal and sensitive data with authorized third parties such as service providers and consultants for processing. Our comprehensive privacy notice is available on our website.

I authorize Bomaid or any Bomaid contracted outsourced providers to collect, process, and request my personal and sensitive data from any healthcare service provider or person who has attended to me or my dependants in the past or who will attend to us in the future or who may be in possession of information about us, including our health status, treatment received or anticipated as well as any other relevant health information for any purpose directly related to our membership or which is authorized in terms of the Medical Schemes Act, the Scheme Rules, or any other legislation, also after the death or termination of membership of any of us.

I authorize Bomaid to deal with my dependants and me electronically and treat electronic communication (such as email, telephone, Bomaid’s digital App) as being the same as written authority and confirmation. I agree further that, where we choose to use electronic methods to transact with Bomaid, we will carry the risk of such use.

Bomaid may use my information for the purpose of marketing (including direct marketing) of its suite of products, benefits, and any other financial or non-financial services offered by itself and its subsidiaries.

I have the right to see any information that Bomaid holds about me, and to have my details removed.

I provide the consent of my own free will without any undue influence from any person whatsoever, and I understand that I can withdraw my consent in writing at any time. The grounds for withdrawing consent should be legitimate, reasonable, and compelling.

The Fund may send your personal information to service providers outside Botswana for the storage or further processing on behalf of Bomaid. Bomaid will ensure to adhere to the provisions of the Data Protection Act before such transborder transfer of your personal information.

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