International Health and Hospital Plan Hong Kong

The premium is age-related. The age-related premium is applied at the first coming premium payment. If you have reached the age of 60 at the time of application, the premium will be increased. The insurance plan must be taken out before you reach the age of 80. A previous medical history may cause an increased premium, exclusion of cover or, in a few particular cases, a rejection of the insurance.

Your policy premium may be subject to Insurance Premium Tax based on your country of residence. If this is the case, the amount of any taxes, levies or charges will be shown on your premium notice. For more detailed information on any taxes in your country of residence, please refer to Bupa ihi or your local representative.

Valid from 1 January 2014 • All amounts are in GBP*

AGE BRACKETS 0-9 10-25 26-44 45-59 60+** Plans available without deductible Hospital Plan 0 2,600 4,078 4,897 5,148 Module 1 Non-Hospitalisation Benefits 0 1,689 2,453 3,037 3,299 Module 2 Medicine & Appliances 0 563 940 1,344 1,388 Plans available with GBP 250 deductible Hospital Plan 0 1,821 3,166 4,085 4,323 Module 1 Non-Hospitalisation Benefits 0 1,188 1,952 2,560 2,780 Module 2 Medicine & Appliances 0 398 754 1,142 1,162 Plans available with GBP 750 deductible Hospital Plan 0 1,450 2,547 3,281 3,470 Module 1 Non-Hospitalisation Benefits 0 624 1,024 1,310 1,443 Module 2 Medicine & Appliances 0 64 124 290 295 Plans available with GBP 2,750 deductible Hospital Plan 0 1,158 2,027 2,580 2,645 Module 1 Non-Hospitalisation Benefits 0 502 798 1,027 1,102 Module 2 Medicine & Appliances 0 51 116 215 216 Plans available with GBP 5,500 deductible Hospital Plan 0 866 1,517 1,937 1,984 Module 1 Non-Hospitalisation Benefits 0 377 601 769 826 Module 2 Medicine & Appliances 0 39 76 155 156 Plans available with GBP 11,000 deductible Hospital Plan 0 824 1,442 1,840 1,884 Module 1 Non-Hospitalisation Benefits 0 358 569 732 786 Module 2 Medicine & Appliances 0 37 72 148 148 Supplementary covers*** Module 3 Medical Evacuation & 0 217 367 429 429 Repatriation Module 4A Dental & Optical 0 334 482 594 594 Module 4B Dental & Optical 0 635 917 1,123 1,123

* Semi-annual premium payments are 53% of annual premium payments. Quarterly premium payments are 27% of annual premium payments. ** Renewals only. *** No deductible applies.

Bupa (Asia) Ltd ° 18/F Berkshire House ° 25 Westlands Road ° Quarry Bay ° Hong Kong ° www.bupa.com.hk Bupa ihi ° Customer Service ° 8 Palægade ° DK-1261 Copenhagen K ° Denmark ° Tel: +45 70 23 00 42 ° Fax: +45 33 32 25 60 ° Email: [email protected] ° www.ihi.com Bupa Global Assistance ° Tel: +45 70 23 24 60 ° Email: [email protected] Bupa ihi is a trading name of Bupa Denmark Services A/S. CVR No. 32451780. Bupa (Asia) Ltd. is authorised and regulated by the Hong Kong Insurance Authority How is the premium paid?

If you have not stated your credit card information on the Application Form, we will send you a premium notice.

As Bupa ihi must receive payment before the cover can start, we advise you to pay the premium within 30 days.

You can choose between the following payment options: || Credit card payment via ihi.com || International credit card: American Express, VISA, Eurocard/ MasterCard, JCB or Diners || International cheque || Eurocheque || International bank transfer to:

Citibank N.A. London United Kingdom Account No.: 08047294 BIC / Swift Code: CITIGB2L Bank Sort Code: 18 50 08 IBAN: GB13CITI18500808047294 Account holder: Bupa Insurance Limited

Danske Bank A/S Holmens Kanal 12 DK-1092 Copenhagen K, Denmark Account No.: 3100-4451130455 BIC / S.W.I.F.T.: DABADKKK IBAN: DK1130004451130455 Account holder: Bupa Insurance Limited

Regardless of how you pay, we kindly ask you to always state your name and birthday or policy number.