PRIVILEGE SUBSCRIPTION

I hereby certify that the foregoing declarations are accurate, complete and fair and have been correctly written to the best of my knowledge and belief.
I have been informed and I accept that any intentional withholding of significant information or false declaration by me or on my behalf may lead to the cancellation
of the insurance cover in accordance with the Luxembourg Law.
I may examine and correct any personal information in the files of the Plan Administrator and the Insurer maintain on my behalf.
For underwriting and claim purposes, I permit any physician who has examined me to give medical data to the physician of the Insurer and/or the Plan Administrator.

I declare that the answers given, whether in my handwriting or not, are true and complete to the best of my knowledge and belief, and will form the basis of the certificate of insurance for my application for the Plans.
I understand that failure to disclose any material fact may invalidate the certificate of insurance.
Note: A material fact is one which 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 give details. Failure to disclose a material fact may invalidate your certificate of insurance resulting in the loss of your benefits.
If I don’t have a Successor, I declare that any Benefits are payable to the WCA social Fund. I declare to have freely acted in my choice to indicate Association WCA asbl as unique beneficiary. I am perfectly aware of the statutes and the social works carried out by the Association.
I agree to inform the FROLSON or Worldwide Crew Association a.s.b.l. (herafter the company) in writing of any change in my circumstances between the date of this application and issue of the certificate of insurance.
I also agree to inform the company of any change of name, change of address etc. that may occur during the life of the Plan. I consent to the company seeking independent verification (if considered necessary) of any of the information given in this application.
Any disputes under the Plans shall be ruled only by courts located in Luxembourg.
Premiums indicated are Tax included. 100 €,$ fees are applied for new subsription.