Subscription Application Form Major Medical Expense Insurance
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- Hannah Ferguson
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1 ajor edical Expense Insurance Page 1 of 5 New policy Addition of dependent Plans Deductible Rehabilitation Change of plan Optimum Plus Option I $1,000 Inclusion Other Optimum Option II $2,000 requency of Payment Security Option III $3,000 Annual Biannual Other Advance Option IV $5,000 Contracting Party Policy number Company name Address Tax ID Number or equivalent Phone Number Legal Representative Information of the Legal Representative Applicant irst name other s maiden name iddle name Initial Surname Date of birth Sex ID Number/Passport Country of residence Residence Address Age Weight Height eet/ts. City Phone Number Cell phone number Office Number ax Name of Company where works Occupation/Position Address Sector Country City
2 ajor edical Expense Insurance Page 2 of 5 Name of dependants Relationship with the policyholder Date of birth Sex Weight Height eet/ts. eet/ts. eet/ts. eet/ts. Are the children from 19 to 24 years old full time students? In case of an affirmative answer, complete the information below. Name of University Phone number Name of University Phone number Section A To the best of your acknowledge and understanding, is there any person named in this application who has had any of the following diseases? 1. Arthritis, neuritis, rheumatism, osteoporosis, lumbago, herniateisk, scoliosis, or other conditions of the dorsal spine or other musculoskeletal disorders? 2. Embolism, thrombosis, migraine, headaches and other cerebrovascular conditions? 3. Epilepsy, fainting, drowsiness, nervous breakdown, anxiety, depression, seizures or other conditions of the brain or Nervous System? 4. Impaired vision, glaucoma, cataract, otitis, labyrinthitis, impaired hearing or other conditions of the sight and of the ear? 5. High blood pressure, heart conditions, murmur, valvular heart disease, angina, heart attack, varicose veins, phlebitis, cardiac pathology or other conditions of the Cardiovascular System? 6. Tuberculosis, emphysema, bronchitis, rhinitis, sinusitis, tonsillitis, asthma, allergies or other conditions of the Respiratory System? 7. Hiatal hernia, gastroesophageal reflux, gastritis, ulcers, colitis, hepatitis, diverticulosis, hemorrhoids, bowel, rectum, liver, gallbladder, pancreas problems and other conditions of the Digestive System? 8. Kidney stones, nephritis, urinary infections, blood in the urine, kidney conditions or other conditions of the Urinary System?
3 ajor edical Expense Insurance Page 3 of 5 9. Prostate, testicles, varicocele conditions or other conditions of the male reproductive organs? 10. Anemia, sickle-cell anemia, hemophilia, clotting disorders, rheumatic fever or other blood conditions? 11. Diabetes, cholesterol or high triglycerides, thyroid conditions, gout, growth or inflammation of lymph nodes or endocrine disorders? 12. Cancer, tumor, cysts, leukemia? Has received chemotherapy, radiotherapy or alternative treatment? Detail below. 13. Prosthetics, implants, amputation, aftermath of some sort of functional limitation? 14. Any deformity, congenital defect or disease, loss of hearing, eye sight or any other member? 15. Has received blood transfusion? Why? 16. Uses or has used psychoactive substances or stimulants? 17. Sexually transmitteiseases, gonorrhea, syphilis, chlamydia, infection with human papilloma virus, herpes or other? 18. Has had any disease, condition, sign, accident or physiological disorder, which has not been mentioned in this form? 19. Are you pregnant? Indicate weeks of pregnancy 20. Abortions, pelvic pain, endometriosis, cysts, any type of mass, cervicitis, breast and ovaries conditions, menstrual disorders, menstrual bleeding, menstrual disturbances or disorders of the reproductive organs? Section B In addition to the diseases mentioned in Section A, to your best understanding and acknowledge, is there any person named in this form that: 1. Has consulted a doctor for medical or surgical treatment, or for advice for any other disease not mentioned in Section A. 2. Has had any alteration of good health not mentioned in Section A or in the first question of this section. 3. Has had a physical exam. If you have answered YES in any part of Section A or Section B, complete the following information (If you require additional space for writing, you can give more details in another sheet) Name of patient Diagnosis and treatment Date Name and address of hospital
4 ajor edical Expense Insurance Page 4 of 5 Name of patient Diagnosis and treatment Date Name and address of hospital Has an insurance company declined, postponed or limited a life, accident or health insurance to you or any of the dependents listed? If you answered yes, name the reason. Have you had or have edical Expenses/Health Insurances? If yes, please detail below Name of the company Policy Number Name of Insured Insurance Company Type of Policy Date of issuance of the policy Did you have any claim? If affirmative, specify It is understood and agreed that: A. Worldwide edical Assurance, Ltd. Corp. (hereinafter: the Company) reserves the right to reject or accept any subscription application. The subscription of this form does not mean the automatic acceptance of the insured. Coverage provided by the Company does not enter into force until the issuance of the policy. B. You agree that all answers given above are complete and true to your best knowledge and understanding. In case of omission, fraudulent or incomplete answers with respect to the stated in this application responses, the Company may exercise its right to terminate or cancel the contract. C. With a photocopy or original of this form, the Applicant authorizes any physician, practitioner, hospital, clinic or other facility, government agency or other medical or medically related person throughout the term of the policy contract to provide the Company all information, including records concerning advice, care or treatment provided to the insured and/or its dependents, without any limitation about information regarding mental illness or drug use or alcohol. D. This form constitutes the English translation of the original document issued in Spanish by the Company. The insured acknowledges that any doubt, discrepancy or controversy arising between the texts in Spanish and English of this form, it shall prevail the text as indicated in the original version in Spanish of this document. Signature of Applicant Date Name of Agent Signature of Agent
5 ajor edical Expense Insurance Page 5 of 5 Additional commentary WOR-WW-OPE-SUS-39
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