FLEXI HEALTH PLAN INDIVIDUAL AND FAMILY HEALTH INSURANCE PLAN APPLICATION FORM
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1 FLEXI HEALTH PLAN INDIVIDUAL AND FAMILY HEALTH INSURANCE PLAN APPLICATION FORM
2 Please use BLOCK letters to complete this form. Proposal form once accepted, becomes part of the policy document. Member Information First Name Middle Name Family Name Full Name: Date of Birth: Gender (M/F): Marital Status: Occupation: Employer: Address: P. O. Box: City: Office Phone: Residence Phone: Fax Number: Nationality: Mobile.: Passport : Member & Dependent Information First Name Middle Name Family Name Gender Relationship Date of Birth Height (cms) Weight (kg) Occupation Passport Number Principal Spouse Dependent 1 Dependent 2 Dependent 3 Previous Insurance Provide Details Where & How Long Medical History Declaration Part 1 Questions Principal Spouse Dep 1 Dep 2 Dep 3 1 Are you in good health and free from any deformity or defect? 2 Have you ever been declined for health and/or life insurance? 3 Have your ever been accepted for health and/or life insurance on sub-standard terms? 4 Do you involve yourself in any dangerous sporting activities OR ride motorcycle? 5. Are you Pregnant now? If, when do you expect to deliver?
3 Medical History Declaration - Part 2 Please answer the following questions which apply to all named applicants. Have you ever been diagnosed or received any treatment ( including Hospital or surgery ) or felt any disorder or pain or had symptoms including ( please tick the relevant box ). If any of the above questions is left unanswered, it will be assumed that the answer is. False declaration shall result in no coverage and cancellation of the insurance policy under consideration in this application as from the effective date, with no premium refund. Questions Principal Spouse Dep 1 Dep 2 Dep 3 a Musculoskeletal & / or Connective tissue System (i.e. fracture, joint or cartilage problems, back bone infections, osteoporosis, arthritis, rheumatism, etc ) b Neoplasms, Cancer, Tumors (Specify type, location, treatment, whether malignant or benign ) c Blood & Blood Forming Organs System ( i.e. anemia, thalasemia, bleeding disorders, blood cell, lumph node problems etc.. ) d Digestive System ( i.e. reflux, ulcers, diverticuli, bleeding-infection-obstructionperforation or problems of the teeth / gum/ mouth / jaw, liver proble, gallbladder or pancreas, anal / rectal polyps etc... e Endocrine, Nutritional, Metabolic and/ or immunity System ( i.e. diabetes, thyroid or pituitary or testes problems, harmone problems, gout, multiple sclerosis, cystic fibrosis, metabolic disorders, etc.. f Nervous System or Sense Organs (i.e. ear injury/infection, vertigo, hearing problems, eye vision problems, muscular dystrophy, brain/nerve degeneration, meningitis, paralysis, seizures, etc.. g Genitourinary System ( i.e. kidney/ bladder infections, renal failure, kidney stones, salpingitis, ovarian cysts, prostate problems, impotence, testicle infections, sperm abnormalities, breast disorders, etc.. h Respiratory System ( i.e. sinusitis, allergies, tonsillitis/laryngitis, bronchitis, emphysema, etc.. i Cardiovascular System ( i.e. stroke, cerebral ischemia, rheumatic fever arthrosclerosis, ischemic heart disease, hypertension, heart valve disease, irregular heart beat, pulmonary embolism, phlebitis, etc..
4 Medical History Declaration - Part 2 ( Cont ) Questions Principal Spouse Dep 1 Dep 2 Dep 3 j Skin Sabcutaneous Tissue (i.e. dermatitis, acne, seborrhea, purities, etc..) k Pregnancy, complication of pregnancy, child birth and the puerperium l Mental Disorders m Infectious and parasitic diseases n Congenital anomalies, hereditary diseases o Certain conditions originating in the perinatal p Injury and poisoning q Previous medical / surgical hospitalization, procedures and operations ( if any ) r Have you ever been tested positive for HIV (AIDS) and for other infectious diseases (e.g. Hepatitis B, C ) or Have any medical condition or symptoms indicative of HIV infection or AIDS? s Any diseases, symptons and complaints not mentioned above t Do you smoke? If yes, please mention what do you smoke and number per day. u Any family member for whom insurance is not applied in this application. (if yes, please provide particulars of existing insurance arrangements). v Have you ever undergone surgery to remove a body organ or structure? ( if yes, specify body organ/structure with date and place of surgery) Family Medical History ( Father, Mother, Siblings) Have any member of your family had symptoms or been diagnosed or received treatment? Inherited disorder or genetic disease Cancer Muscular Dystrophy Diabetes Hemophilia Multiple Sclerosis Nervous System/ Sense Organ Disease Illness of Cardiovascular System Mental Illness or Disorder Signature of Applicants Place: Date of Signing the proposal:
5 Medical History Declaration - Part 2 ( Cont ) Answers to Questions ( if answered as ) Principal Spouse Dep 1 Dep 2 Dep 3 Chronic Diseases: A disease with one or more of the following characteristics: lasts 3 months or more, leaves residual disability, is caused by non-reversible pathological alteration, requires special training of the patient for rehabilitation, or may require la long period of supervision, observation, or case. In case the answer is YES to any of the conditions/diseases above, please specify full details on additional questionnaire attached to this application form. Declaration: I/We hereby declare with respect to both, myself and my dependants that to the best of my knowledge and belief, the statement on application are full, true and correct and have declared all material facts related to this application. I/We understand that non-disclosure or misrepresentation of any material fact may invalidate the quoted terms. I/We agree that all the documents issued in connection with the policy shall be read together. If my application gets accepted, I/We agree to be bound by the terms and conditions of the policy. I/We hereby authorize any doctor, Hospital, Clinic or Medical Provider, any Insurance Company or any other Company, institution or any other person who has any record or information about me and/or any of my family members to provider Al Sagr National Insurance Company, with the complete information, including copies of their records with reference to any sickness or accident, any treatment, examination, advice or hospitalization or any other medical information required by Al Sagr National Insurance Company. The Coverage of Health Services provided by Al Sagr National Insurance Company is described in the policy wording. By signing this for, I/We acknowledge that I/We read, understood and agree to the terms and conditions as stated in the policy wording. I/We agree that after acceptance of the quoted premiums in the quotation, I/We shall be liable to pay all the premiums to Al Sagr National Insurance Company as per the specified and selected plan of our choice. Al Sagr National Insurance Company reserves the right to reject any authorization/claims request for conditions (preexisting, chronic) not declared by the applicant at the inception of the policy. Date & place of signing Signature
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Before any question is answered, please read carefully the declaration at the end of this Proposal, which must be signed and dated. Please ensure that the person to be insured answers all questions fully
OUR POLICIES. Prior Authorization for prescriptions is $10.00 for each authorization completed.
OUR POLICIES Effective April 1, 2008, due to continued decreasing insurance reimbursements, we will begin strictly enforcing fees for certain tasks that we perform on behalf of our patients. Phone calls
Desired Effective Date:
Employer: Desired Effective Date: Level of Coverage: Last Name: Plan Chosen: Employee Health Evaluation & Enrollment Form INSTRUCTION: THIS FORM IS TO BE COMPLETED BY THE EMPLOYEE Employer Information
Application for Membership
Application for Membership Please complete in BLOCK LETTERS Administered by: Medscheme Holdings (Pty) Ltd. Tel 0860 100 080 E-mail nedgroupregistry@medscheme.co.za Fax number 0860 111 784 COMPULSORY INFORMATION
Please Print in Black Ink To Be Completed by Proposed Insured. Proposed Insured s Name Last First MI. DOB Sex SSN - - Month/Day/Year.
Application for Hospital Confinement Indemnity Insurance (A49000 Series) Application to: American Family Life Assurance Company of Columbus (herein referred to as Aflac) Worldwide Headquarters Columbus,