HEALTH INSURANCE PROPOSAL FORM SELECT AND SELECT XL
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1 HEALTH INSURANCE PROPOSAL FORM SELECT AND SELECT XL Proposal no. Policy no. Individual cnudurwf wlcaimwa Company inufcnuk National ID Card cdwk.id.iawa Registration Certificate ctekifctes IrcTcsijwr Occupation: WriaWd egwfizwv Nature of Business: ctwvwb egirwfwyiv Work Permit ctimrwp ckov Passport ctopcswp Company/Office/Applicant s Name: cnwn egutcnwkilcpea /cnwn eguhifoa /cnwn eginufcnuk ID No. urwbcnwn ID.iawa Date of Birth: ckirwt cnwfua Male cnehirif Female cnehcnwa Reg No. urwbcnwn IrcTcsijwr Permanent Address (as in ID card): (cswtogwv iawgudwk IDwa) csercdea ImiaWd Nationality: umuawg Postal Address (fill below): csercdea WrukuTcsOp Contact Name: cnwn egwhim ELug House/Building name: cnwn egutwrwmia /cnwnegeg Contact No: urwbcnwn egwhim ELug Road: ugwm Postal Code: cdok clwtcsop District: cswvwa Atoll,Isand: cswr,ulotwa clemia Fax: csckef Please Choose the Policy of Interest SELECT SELECT XL If Family Insurance, please specify the number of members proposed. Adult Children (Under 18 years) IMPORTANT NOTICE Please read through the following notes that are relevant to any of either policy you may enroll under. 1. Any of either policy may have a proposer, maximum aged 59 years when applying for the policy. 2. Family policy holders may have a dependent spouse of maximum age of 59 years when applying for the policy. 3. Family policy holders may have dependent Unmarried Children under 21 years of age when applying for insurance. 4. Any of either policy proposers may continue health insurance up to the age of Under family insurance, a dependent spouse may continue in the policy till the age of Under family insurance, dependent children may continue policy up to the age of 21 years when unmarried. 7. All documents of Medical Check-up as per the Check List provided would not be reimbursed under any of either policy. 8.The policy is only for those residing in the Maldives for more than 6 months in a 12 months period. This is not for overseas travelers who remain out of the country for a period more than 6 months. 9. Policy Coverage is for 12 months period from the issue of Insurance, whereby the policy need be renewed before the end of the period. Allied Insurance Company of the Maldives Pvt. Ltd. (C-43/84), Fen Building, 3rd floor, Ameenee Magu, Male, 20375, Maldives info@allied.mv youtube.com/alliedmv facebook.com/alliedmv twitter.com/alliedmv allied.mv
2 Nature of Work (Please tick whichever is applicable) Insured Person engaged in professional, administrative, managerial, clerical and non-manual operations. Insured Persons engaged in work of supervisory nature but not involved in manual labor. Insured Persons engaged occasionally or generally in manual work which involves the use of tools or machinery. Coverage Inpatient Only (Discount applied) Family Your Dependents Particulars: Only if the Family Insurance Scheme is required Full Name Passport/ID No. Age Date of Birth Nationality Weight Height Declarations: 1. Do you or any of the persons to be insured have Health Insurance with us or any other company? If Yes please attach a copy of the existing policy schedule. Yes No 2. Have you or any of the persons to be insured as your dependents: None A. Suffered or have any physical defects, infirmity or congenital conditions? B. Currently under observation or receiving treatment or taking any medication C. Undergone any surgical operation or suffered any disease or injury? D. Ever been advised to have a surgical operation which has not been performed?
3 3. Have you or any of the persons to be insured as your dependents ever been told that you or they have suffered from or had been treated for any of the following? None A. Chronic cough, spitting of blood, asthma, hay fever, pleurisy, tuberculosis or any other disease of the respiratory system? B. High or low blood pressure, heart disease, chest pain, heart attack, shortness of breath, palpitation or any other heart disorder? C. Epilepsy, fits, dizziness, mental or nervous disorder? D. Diabetes, sugar or blood in urine, kidney, colic or hernia? E. Disease of the eyes, ears, nose or throat? F. Arthritis, sciatica, rheumatisms, back, spine, bone, joint, muscle or rectal disorder? G. Ulcer or disorder of the stomach. Intestines, hemorrhoids or rectal disorder? H. Gall bladder stone or liver disease or any type of hepatitis? I. Cancer, tumor or growth of any kind of any organ system? J. Anemia, thyroid disorder (such as Goiter) or Rheumatic Fever? K. Sexually transmitted disease such as syphilis, gonorrhea or non-specific arthritis? L. AIDS or AIDS-related conditions? M. Smoking/Chewing Tobacco? If Yes, please specify. per day. If more than one person smokes please write in the respective order of the check marks. N. Any illness or injury not mentioned above? O. Any other form of Addition? If Yes, please specify
4 4. If any of the answers is Yes to questions in 2 & 3, please give details below and number your answers to correspond with the number of questions to which the answer is applied.
5 Further Personal Particulars: Please fill in appropriate order of, and children for family insurance. Blood Type: Usual Doctor/Physician of Choice: Address: Known Allergies:
6 Insurance History: 5. Have you or your dependents application for medical or hospitalization type of policy been declined, restricted or accepted at other than normal terms? If Yes, please state reason and provide the name of the Insurance Company. Name: Reason: Declaration by : (To be read carefully before signing by the ) I/We hereby declare that the above answers and statements are true, and that I/We have withheld no information whatsoever regarding this proposal. I/We agree that this Declaration and answers given above, as well as any proposal or declaration statement made in here by me/ourselves or anyone acting on my behalf shall form the basis of the contract between me/ourselves and the Insurance Company. I/We hereby further declare that I/We agree that in the event the declaration shall contain any misstatement, misrepresentation, suppression and or fraud, the issuance of the policy shall not be deemed to be a waiver of such misstatement, misrepresentation, suppression and or fraud. I/We hereby authorise any hospital, surgeon, medical practitioner or clinic or other person who attended to me/ us for any reason to disclose to the Insurance Company any and all information with respect to any illness or injury and to provide copies of all hospital or medical records/ certifications, including any earlier medical history. A photocopy of this authorisation shall be considered as effective and valid as the original. I/We acknowledge that the liability of the Insurance Company does not commence until this proposal is accepted by and premium paid to the Insurance Company. I/We also upon filling the form are well aware of the policy I have chosen to enroll in. I/We have also read the Important Notice on the cover page of the proposal form and are aware of their significance and balance in clearly informing of policy limitations. DecIaration: I/We desire to effect with the Company an insurance, in the terms of the Policy used for this class of business and I/We warrant that the above statements and particulars are correct and complete. I/We agree that this proposal shall be the basis of the contract and part of the insurance between myself/ourselves and the Company. /udnwgulwa iawgumof clwsoporcp im.evemuneb cnwgwn cscnerwauxcnia ukeaiawncnufcnuk wyit cnitwm egutogwvctogcaea iawkwtwdcawm iawkwtclubua WviawgIsilop im cnemudnwgulwa /udnwgulwa iawswmwk ulcbwa udnwgiawm egumuyikeyil cscnerwauxcnia IkwaclwsOporcp im idwa.evetwmuluawm whcaws idwa wmwhiruf emcnea csevikwtwmuluawm Whiruh WviawfId cnemudnwgulwa /udnwgulwa.evemwvurwrcqia cnemudnwgulwa /udnwgulwa cswmwkcaeawb egisilopim Signature: Date: Office use only Rate: Premium: Agent s Name: Documents required with the Proposal: itekwt EhejcnwLwawSuh ukea iawmof Copy of ID. Card Ipok udwk.id.iawa THIS INSURANCE WILL NOT BE IN FORCE UNTIL THE PROPOSAL HAS BEEN ACCEPTED BY THE COMPANY.evencnumutwgiawlwb clwsoporcp cninufcnuk,inesef cneverukulwmwa cswacscnerwauxcnia im
7 FAMILY AND INDIVIDUAL HEALTH INSURANCE Pre-Insurance Health Checkup Name: ID No: HEMATHOLOGY URINE & STOOL ANALYSIS IMAGING OTHERS Blood R/E and ESR Serum Urea Serum Creatinine Serum Uric Acid Urine Analysis Chest X ray ECG 12 leads Abdomen USG Female above 35 yrs Pap Smear Fasting Blood Sugar Post Prandial Blood Sugar Serum Blirubin Total SGPT/ALT Total Cholestrol Serum Magnesium Hepatitis BsAg TSH Male above 50 yrs PSA Levels FOR OFFICE USE ONLY Date Recieved: Checked By: Signature & Stamp:
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INDIVIDUAL HEALTH INSURANCE APPLICATION The Insurer retains the right to contact the applicant if any question is not explained in detail or if additional information is required. New policy Additional
Please Present Insurance Card at Each Office Visit
PATIENT REGISTRATION FORM RONALD J ESCUDERO, MD, FACS Please print clearly and fill out completely Patient Legal Name Birthdate Age Address Social Security # City ST ZIP Email Phone Numbers ( ) Home (
Patient s Name: Age: Social Security: Height: Weight: Street Address: City: State: Zip: Mailing Address (if different): City: State: Zip:
PATIENT INFORMATION: Patient s D.O.B: Age: Social Security: Height: Weight: Street Address: City: State: Zip: Mailing Address (if different): City: State: Zip: Home Phone: Cell Phone: Work Phone: Email
PROFESSIONAL SPORTSPERSON'S ACCIDENT & ILLNESS INSURANCE PROPOSAL / MEDICAL APPLICATION FORM
INSURED AT LLOYD'S OF LONDON PROFESSIONAL SPORTSPERSON'S ACCIDENT & ILLNESS INSURANCE PROPOSAL / MEDICAL APPLICATION FORM AGENT CAUNCE O'HARA & CO LTD CITY WHARF NEW BAILEY STREET MANCHESTER M3 5ER TEL:
PERSONAL STATEMENT - INSURANCE APPLICATION
PERSONAL STATEMENT - INSURANCE APPLICATION INFORMATION NOTICE The Grow Super group insurance for death (including Terminal Illness), Total and Permanent Disablement (TPD) and Income Protection (IP) cover
New Patient Registration Form
New Patient Registration Form PATIENT INFORMATION Last name: First Name: Middle Initial: Marital Status: Single Married Divorced Other Social Security #: Birth Sex: M F Street Address: City: State/Zip
Fax this Application Form to:
Requirements before submitting this application form: 1. Please complete the Medical Health Declaration section on this Application Form. 2. Please read and sign the Declaration at the bottom of the Application.
Gary W. White, M.D. Dean A. Cione, M.D. Jeremy S. Carrasco, M.D. Ramsey A. Stone, M.D
PATIENT REGISTRATION FORM First Name: MI: Last Name: Date of Birth: Address: Apt#: City: State: Zip: Home Phone: ( ) Cell Phone: ( ) Work Phone ( ) SS#: - - SEX: Female Male E-mail Address: Ethnicity:
Patient Information. Last First MI (Preferred Name) Male Female Married Single Child. City State Zip Code Emergency Contact/Relation Phone
LEWIS C. COLE DMD Family and Cosmetic Dentistry 525 ENERGY CENTER BLVD SUITE 1603 NORTHPORT, AL 35473 PHONE 205.344.6900 FAX 205.344.6910 www.lewiscoledentistry.com Patient Name: Patient Information Date:
Patient Information. Name Date. Address City Zip. Age Date of Birth / / Marital Status M S D W. Social Security # Driver s License #
Patient Information Name Date Address City Zip Age Date of Birth / / Marital Status M S D W # of Children Social Security # Driver s License # May Ashby Chiropractic Clinic communicate with you by: Telephone
*SA GH1* Application for insurance cover form and personal health statement
Application for insurance cover form and personal health statement Please complete this form in BLACK PEN and CAPITAL LETTERS. ABOUT THIS FORM Complete this form if you wish to apply: > > for Death cover
PATIENT INFORMATION FORM RICHARD L. MALINICK, M.D. ORTHOPAEDIC SURGERY 1125 Via Verde, San Dimas, CA
Email Address Last Name First Name Previous Name Address City State Zip Country Social Security - - Home Phone - - Cell Phone - - Work Phone - - Ext Drivers License State Responsible Party SELF (use info
PERSONAL INFORMATION
Thank you for selecting our team for your dental care. We are pleased to welcome you to our practice! To help us better serve you and meet your dental healthcare needs, please complete the following forms.
Life Insurance Application Part B Connecticut Version
American General Life Insurance Company, Houston, TX The United States Life Insurance Company in the City of New York, New York, NY AIG Life Insurance Company, Wilmington, DE Subsidiaries of American International
Illinois Standard Health Employee Application for Small Employers
Illinois Standard Health Employee Application for Small Employers INSURER USE ONLY Policy/Group No. Section No. Effective Date New Hire Waiting Period For assistance in completing this application, please
Patient Last Name: First MI. Responsible Party (if a minor) Address: (Street or PO Box) (City) (State) (Zip) Home Phone: Cell Phone: Work Phone:
Patient Last Name: First MI Responsible Party (if a minor) Address: (Street or PO Box) (City) (State) (Zip) Home Phone: Cell Phone: Work Phone: Date of Birth: Social Security No.: Sex: Marital Status:
PATIENT INFORMATION. SPOUSE INFORMATION (if applicable) Home phone (if diff.): Cell phone: Work phone:
PATIENT INFORMATION Full name: Preferred name: Home address: Home phone: City/State/ZIP: Cell phone: Social Security #:_ Sex: M F Date of birth: Marital status: married single divorced widowed E-mail address:
Chong S Kim, MD ENT and Facial Plastic Surgeon
Chong S Kim, MD ENT and Facial Plastic Surgeon 100 Commons Way, Suite 701 300 Perrine Rd., Suite 301 Holmdel, NJ 07733 Old Bridge, N.J 08857 Phone: 732-796-0182 Phone: 732-727-1355 Fax: 732-796-0186 Fax: