United Nations Short-term Insurance Application Form
This file is an application form for short-term insurance policies offered by the United Nations. It includes fields for personal information, employment details, and agreement to salary deductions for medical insurance coverage. The form must be submitted to the Health and Life Insurance Section (HLIS).
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How do I fill this out?
To fill out this form, start by entering your personal information, including your name and date of birth. Next, provide your employment details, such as your department and grade. Finally, agree to the terms and sign the form.
How to fill out the United Nations Short-term Insurance Application Form?
1
Enter your last and first name.
2
Provide your date of birth and select your sex.
3
Input your employment details including index number, grade, department, room, division, and extension.
4
Agree to the terms and authorize salary deductions.
5
Sign and date the form.
Who needs the United Nations Short-term Insurance Application Form?
1
Conference attendees needing short-term insurance coverage.
2
Temporary United Nations employees.
3
Consultants and contractors requiring emergency medical coverage.
4
Event participants requiring short-term medical insurance.
5
Individuals needing immediate hospitalization coverage while working for the United Nations.
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What are the instructions for submitting this form?
Submit the completed form to the Health and Life Insurance Section (HLIS) via email at hlis@un.org or fax to (917) 367-1670. Ensure all fields are filled accurately, and the form is signed and dated. Double-check for completeness before submission to avoid any delays or rejections. For physical submission, hand-deliver to the HLIS office at the United Nations headquarters.
What are the important dates for this form in 2024 and 2025?
Ensure to submit the form before the start of your employment period. For 2024 and 2025, submission deadlines are January 1st and July 1st.
What is the purpose of this form?
This form is designed to provide short-term insurance coverage for individuals working temporarily or attending events organized by the United Nations. It allows applicants to receive emergency and immediate medical treatment coverage, ensuring their well-being during their period of employment or participation in UN events. The form captures essential personal and employment details, making it necessary for processing the insurance coverage application.
Tell me about this form and its components and fields line-by-line.
- 1. Name: Enter your last and first name.
- 2. Date of Birth: Provide your date of birth in the format DD/MM/YY.
- 3. Sex: Select your sex: M, F, or Other.
- 4. Index No.: Input your index number.
- 5. Grade/Step: Provide your grade and step.
- 6. Department: Enter your department information.
- 7. Room: Provide the room number of your office.
- 8. Division: Enter the division you work in.
- 9. Phone Extension: Provide your phone extension number.
- 10. Local Address: Enter your local address during the employment period.
- 11. Period of Employment: Provide the start and end dates of your employment.
- 12. Agreement: Agree to the terms for salary deductions for medical insurance coverage.
- 13. Signature: Sign and date the form.
What happens if I fail to submit this form?
If you fail to submit this form, you won't be covered under the UN's short-term insurance policy. This may result in personal financial liability for medical and hospitalization costs.
- Lack of Coverage: You will not have any insurance coverage for emergency medical procedures.
- Personal Financial Liability: Any medical and hospitalization costs will have to be paid out-of-pocket.
- Policy Non-Compliance: Failure to comply with policy requirements may affect your relationship with the United Nations.
How do I know when to use this form?
- 1. Conference Participation: Needed for obtaining insurance when attending a United Nations conference.
- 2. Temporary Employment: Required for short-term United Nations employees needing medical coverage.
- 3. Consultancy Services: Consultants require this form to ensure they have medical insurance during their service period.
- 4. Contract Work: Contractors must submit this form for insurance coverage during their contract with the United Nations.
- 5. Event Attendance: Used by individuals attending events organized by the United Nations needing short-term medical insurance.
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