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SICOM MyCare Proposal Form-JULY2015
SICOM MyCare Proposal Form-JULY2015
MEDICAL INSURANCE
Agency:
Code:
Date:
Names:
Date of Birth:
Height:
ID Number:
m
cm
| | | | | | | |
Weight:
| | | | | |
Kg
Postal Address:
Nationality:
Country of residence:
Name of Employer:
Occupation:
E-mail:
Tel:
Mobile:
Occupation:
I D: | | | | | | | | | | | | | | |
DOB:
Son
Daughter
Height:
Other
2 Name:
Occupation:
I D: | | | | | | | | | | | | | | |
DOB:
Son
Daughter
Kg
cm. Weight:
Kg
Specify:
Height:
Other
cm. Weight:
Specify:
3. Name:______________________________
Occupation:_____________________________________
I D: | | | | | | | | | | | | | | |
DOB:
Relationship
to applicant:
3. Plan and
SchemeSpouse
Son
4. Name: ____________________________
Daughter
Son
Other
cm. Weight:
Kg
Specify:
Occupation: __________________________
I D: | | | | | | | | | | | | | | |
Relationship to applicant: Spouse
Height:
Other
Specify: __________________________________
3. Plan Selection
Plan
CLASSIC
GOLD
PLATINUM
a.
PROPOSAL FORM
MEDICAL INSURANCE
(Choose one of the following plans and note that the Applicant plan cannot be lower than the dependents)
Applicant
I
II
III
A
B
E
Spouse
I
II
III
A
B
E
1st Dependent
I
II
III
Are any of the persons to be covered already or was previously insured under another medical
scheme?
If yes please give details and submit claims history for last 2 years:
b.
Have you or any of the persons to be covered ever been denied, postponed or received quotation
for medical insurance at special terms and conditions including increase in premium? If Yes,
please give details
4. Medical Information
Please answer the following questions by YES or NO as they apply to each of the persons named.
NOTE: Any Pre-Existing Condition not disclosed at Proposal will invalidate claims directly or indirectly relating to it
A. Have any of the named persons ever been diagnosed with or
received treatment or advice for any condition or illness relating
to one of the following categories listed below?
Indicate specific condition by underlining the specific condition.
e.g. cardiac murmurs, high blood pressure, chest pain,
A1. HEART,
tightness of chest, palpitations, coronary circulatory
BLOOD VESSELS,
system thrombosis, valve defects, shortness of breath,
OR
stroke, diabetes, high cholesterol, cramps during light
CIRCULATORY
exercise, or walking, varicose veins, cardiac
SYSTEM
irregularities, swelling of the legs, or leg ulcers
A2.RESPIRATORY
SYSTEM OR
LUNGS
A3. DIGESTIVE
SYSTEM OR
LIVER
A4. KIDNEYS OR
BLADDER
A5. NERVOUS
SYSTEM
Applicant
Spouse
1st
Dependent
2nd
Dependent
3rd
Dependent
PROPOSAL FORM
MEDICAL INSURANCE
A8.REPRODUCTI
VE SYSTEM
(MALE &
FEMALE)
A9. BREAST
B13. The above questions are not all inclusive. Should any named person have any condition that is not covered by these
questions, please provide such information in the space below:
If any answer to the above questions are YES, please give full details below:
Question
No
Name of Patient
Nature of Medical
Conditions
Further treatment
or consultation
needed
2nd Dependent
3rd Dependent
Applicant
Spouse
1st Dependent
PROPOSAL FORM
MEDICAL INSURANCE
| | | | | | | |
3 Consecutive months
Cash
| | | | | |
Yearly
Salary Deduction
7. Declaration
I/We, the undersigned, do hereby declare and warrant that all information given in the proposal form,
whether in my/Our handwriting or not, is true and complete.
I/We, agree to be legally responsible for the accuracy of information in the Proposal Form and for
payment of premiums.
I/We, agree that the statements in this proposal shall be the basis of the proposed contract, that any
misstatement or omission of material fact therein may lead to any contract made being declared void
and that in such event all moneys paid in respect thereof shall be forfeited.
I/We, hereby authorize and request any doctor, other person or institution who may be in possession
of, or later acquire any information concerning my/our health, and that of my/our family, to disclose to
SICOM General Insurance Ltd/ Linkham Services Ltd, if required
I/We, agree that cover will commence when the full premium is paid and SICOM General Insurance Ltd/
Linkham Services Ltd have conveyed acceptance of the risk to the applicant or agent as the case may
be.
I/We understand and agree that SICOM General Insurance Ltd/ Linkham Services Ltd have the right to
decline any application without justification
Date:
Signature:
Applicant
Spouse
In accordance with the Data Protection Act 2004, SICOM General Insurance Ltd/Linkham Services Ltd as data controllers will
collect and maintain personal information in order to underwrite and administer the policies of insurance that we issue. All
personal information is treated with the utmost confidentiality and with appropriate levels of security. We will not keep
Your information longer than is necessary.
Your information will be protected from accidental or unauthorised disclosure. We will only reveal Your information if it is
allowed by law, authorised by You, to prevent fraud, or in order that We can liaise with Our agents in the administration of
this policy.
Under the terms of the Act You have the right to ask for a copy of any information We hold on You upon payment of an
administrative fee and to require a correction of any incorrect information held. Any inaccurate or misleading data will be
corrected as soon as possible.
Linkham Services Ltd are the Project Administrator of SICOM MyCare Health Insurance for SICOM General
Insurance Ltd