As the headquarters of ihi Bupa are moving from Denmark to the UK on 2nd December 2009, at that time the named insurer on your insurance policy, which is currently the Danish branch of Bupa Insurance Limited (called Bupa Denmark, filial af Bupa Insurance Limited, England) will revert to its UK parent company, Bupa Insurance Limited. Your insurer will not be changing as both Bupa Insurance Limited and the Danish branch are parts of the same company. Your premium USD Valid from 1 January 2009 The premium is age-related. The age-related premium is applied at the first coming premium USD 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 a higher premium, and in some instances, an exclusion in the insurance cover. 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 ihi Bupa or your local representative. Annual premium per person in USD* Age brackets 0-9 10-25 26-44 45-59 60+** Plans available without deductible Hospital Plan 0 2,959 4,640 5,573 5,858 Module 1 Non-Hospitalisation Benefits 0 1,832 2,656 3,291 3,579 Module 2 Medicine & Appliances 0 543 914 1,336 1,377 International Health and Hospital Plan Plans available with USD 400 deductible Hospital Plan 0 2,009 3,630 4,518 4,878 Module 1 Non-Hospitalisation Benefits 0 1,292 2,051 2,718 3,016 Module 2 Medicine & Appliances 0 380 722 1,091 1,152 Plans available with USD 1,600 deductible Hospital Plan 0 1,468 2,661 3,388 3,655 Module 1 Non-Hospitalisation Benefits 0 611 1,035 1,343 1,494 Module 2 Medicine & Appliances 0 25 51 62 64 Plans available with USD 5,000 deductible Hospital Plan 0 1,162 2,109 2,693 2,795 Module 1 Non-Hospitalisation Benefits 0 485 820 1,048 1,144 Module 2 Medicine & Appliances 0 20 38 48 48 - ENGLISH Plans available with USD 10,000 deductible Hospital Plan 0 872 1,581 2,020 2,096 05.33.2008 Module 1 Non-Hospitalisation Benefits 0 365 616 785 859 Module 2 Medicine & Appliances 0 15 30 37 37 211E9-31/ Supplementary covers*** Module 3 Medical Evacuation & Repatriation 0 339 572 669 669 Module 4A Dental & Optical 0 491 708 874 874 Module 4B Dental & Optical 0 934 1,347 1,650 1,650 * Semi-annual premium payments are 53% of annual premium payments. Quarterly premium payments are 27% of annual premium payments. ** Renewals only. *** No deductible applies. E. & O. E. USD 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 ihi Bupa 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 our bank: International Health and Hospital Plan Citibank N.A. London United Kingdom USD Account No.: 8237581 BIC / Swift Code: CITIGB2L Bank Sort Code: 18 50 08 IBAN: GB63CITI18500808237581 Account holder: Bupa Denmark, branch of Bupa Insurance Limited, England Regardless of how you pay, we kindly ask you to always state your name and birthday or policy number. - ENGLISH 05.33.2008 211E9-31/ ihi Bupa ● 8 Palaegade ● DK-1261 Copenhagen K ● Denmark ● Tel: +45 33 15 30 99 ● Fax: +45 33 32 25 60 E-mail: [email protected] ● www.ihi.com ● Medical Centre: +45 33 15 33 00 / E-mail: [email protected] ihi Bupa is the trading identity of Bupa Denmark, filial af Bupa Insurance Limited, England (Bupa Denmark, branch of Bupa Insurance Limited, England). CVR 31602742. Bupa Insurance Limited is registered in England No 3956433.