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Medical Application Form



INDIVIDUAL MEDICAL INSURANCE APPLICATION FORM
 
Personal Details
  Name: CPR:
  Sex: Male Female Nationality:
  Date of Birth: Occupation:
               
  Weight: Height: Applicant Status : Married Single

Dependents to be included

Name

Sex

Relationship

CPR

DOB

Weight (kgs)

Height (meters)

Address
Physical Address Villa No. Road No. Block No.
P.O. Box Town/City Country
Contact No.(s) Telefax No.
E-mail Address  
Type of Cover Required
Elite Gold Elite Riaya Himaya Himaya 2

Effective Date     
Previous Medical History
Did you (or any of the listed members) suffer from any serious illness or underwent any major surgical operation in the past 5 years? OR, do you (or any of the listed members) currently have an illness or undergoing a certain medical treatment?
No Yes. If Yes please state the details below :

Have been diagnosed with any form of cancer or have suffered from any pre-malignant conditions including familial colorectal polyposis, cancer-in-situ, papilloma of the bladder, abnormal class IV cervical smear test, polyps (intestinal and of the urinary bladder), oral leukoplakia.
No Yes. If Yes please state the details below:

Have been diagnosed with any form of cardiovascular disease or have not suffered from any underlying conditions including hypertension, arteriosclerosis, diabetes mellitus, abnormal ECG, hyperlipidaemia, hyperuricemia and obesity.
No Yes. If Yes please state the details below or attach to this form:
Medical Condition
Did you (or any of the listed members) or any member of your family have any of the following illnesses/disorders? Please tick the appropriate box and underline the illness/condition referred to. All questions must be answered.    
   

Yes

No

Name of Dependents

a)

Tumours: Benign / Malignant

 

b)

Headache / Migraine Disorders

 

c)

Mental Illness / Nervous Disorders

 

d)

Eye Diseases

 

e)

Asthma / Allergies / Pulmonary Diseases

 

f)

Cardiovascular Diseases / Arterial Hypertension 

 

g)

Liver / Stomach / Intestinal Diseases

 

h)

Diabetes / Other Hormone Diseases

 

i)

Urinary Track Diseases / Diseases of the Sexual Organs

 

j)

Rheumatism / Muscle, Joint or Bone Disease

 

k)

Back Problems

 

l)

Skin Diseases

 

m)

Cosmetic Operations

 

n)

Any other diseases / disorders 

 

o)

Have you been tested for HIV-antibodies

 

p)

 Hepatitis B or C

 

q)

Endometriosis, ovarian growth, fibroid, irregular menstrual bleeding or any other gynaecological disease or disorder.

 

r)

Any other illnesses, congenital or hereditary  disorders, any hospitalisations or physical impairment not listed above

 

Do you take or have taken any kind of medicine on a regular basis? No Yes

If Yes, please state type, condition obtaining treatment for and medication dosage:

Are you a smoker (or any of the listed members) ?
No Yes. Please state number of cigarettes a day
Previous Insurance History
Have you (or any listed members) had any Medical Insurance with ArigCare previously?
No Yes. Please state the policy number and expiry date
Have you (or any listed members) had any Medical Insurance other than ArigCare in the past 3 years?
No Yes. Please state name of insurers and number of years with each

Declaration

I declare that to the best of my knowledge and belief the statements on this application form are full, true and correct, and I agree that the acceptance of my application shall be on the basis of these statements and any disclosure of material facts may lead to the rejection of any claim.  

I Agree