Declaration

I hereby declare that:

• I have received and read the information booklet relating to the health insurance contract underwritten by WCA.
• I have provided all the information requested in a complete, honest, and accurate manner. I acknowledge that this questionnaire must be completed by each person to be insured and that all questions must be answered.
• I am aware that, in accordance with Article L.113-8 of the Insurance Code, and independently of the ordinary causes of nullity and subject to the provisions of Article L.132-26 of the Insurance Code, the cover granted to the Member by the Insurer shall be null and void in the event of concealment or intentional misrepresentation by the Member, whether at the time of subscription or during the term of the contract, when such concealment or misrepresentation alters the nature of the risk or reduces the Insurer’s assessment thereof, even if the omitted or misrepresented risk has had no influence on the occurrence of the claim.
• I am aware that, in the event of a claim or any request for assistance, the deliberate and voluntary submission of inaccurate or fraudulent documents will result in the forfeiture of cover, without reimbursement of any contributions already paid.
• I reside and work outside the borders of the country of which I am a national.
• I undertake to report any change relating to my family members within fifteen (15) days of becoming aware of such change.

I declare that the answers provided, whether written by me or on my behalf, are true and complete to the best of my knowledge and belief and shall form the basis of the certificate of insurance issued under my application for the Plans.

I understand that failure to disclose any material fact may invalidate the certificate of insurance.
A material fact is any information that may influence the assessment or acceptance of your application for the Plans. If you are in any doubt as to the relevance of any information, please provide full details. Failure to disclose a material fact may result in the loss of your benefits.

If I do not designate a successor, I declare that any benefits shall be payable to the WCA Social Fund. I confirm that I have freely chosen to designate Association WCA asbl as the sole beneficiary and that I am fully aware of its statutes and social activities.

I agree to inform FROLSON or Worldwide Crew Association a.s.b.l. (hereinafter referred to as “the Company”) in writing of any change in my circumstances occurring between the date of this application and the issuance of the certificate of insurance. I also agree to notify the Company of any change of name, address, or other personal details that may occur during the term of the Plan. I consent to the Company seeking independent verification, if deemed necessary, of any information provided in this application.

Annual taxes & WCA fees: 50 (€ / $ / £)

Any dispute arising under the Plans shall be subject exclusively to the jurisdiction of the courts of Luxembourg.

I acknowledge that I have read and unconditionally accept the General Conditions applicable to each option selected.