MEMBERSHIP APPLICATION FORM

Instructions:
1. Please complete in BLOCK CAPITALS marking the appropriate box(es) with an X New Renewal

2. This Application Form must be fully completed Upgrade Downgrade

Section1:1: Details
Section Details of
ofMain
MainMember
Member
Title: Mr Mrs Ms

Member Surname:

Member First Name:

Gender: Male Female

Date of Birth: D D M M Y Y Y Y

ID Number: Please provide us with a copy

Name of Company:

Employee Number (Corporate Clients Only):

Date of employment: Date of Confirmation: (Company Seal & HR Signature Mandatory)

Marital Status: Occupation:

Residential Address:

Phone Number: Home Mobile

Email Address:

Plan Chosen:

Bank
BankDetails of Main
Details of MainMember
Memberforfor Claims
Claims Refund
Refund

Bank Name:

Bank Account Number:

Section
Section2:
2: Policy Details
Policy Details

Cover Start Date: D D M M Y Y Y Y

Method of Payment:
Annually (Specify Mode of Payment):

Monthly (Specify Mode of Payment):

Section
Section3:
3: Dependants
Dependants toto
bebe Covered
Covered
You may include your Spouse/Partner under the age of 65 and unmarried children under the age of 25 if in full time education
(Proof should be provided). Should you require more space, please continue on a separate sheet and attach
it to this application.
Details Dependent 1 Dependent 2 Dependent 3 Dependent 4

Title Mr Mrs Miss Mr Mrs Miss Mr Mrs Miss Mr Mrs Miss

Dependant Surname

Dependant First Name

Gender

Date of Birth DD/MM/ YYYY DD/MM/ YYYY DD/MM/ YYYY DD/MM/ YYYY
ID Number

Nationality

Relation to Member

Plan Chosen

Eagle Insurance Limited c/o Medscheme T: +230 460 9208

BRN: C06002277 1st Floor, Tower A , 1Cybercity E: health@eagle.mu
eagle.mu Ebene , Mauritius
Eagle Insurance

Administered by A member of IBL

MEMBERSHIP APPLICATION FORM

Section
Section4:
4: Adult MembersPhysical
Adult Members Physical Details
Details

Self Spouse
Weight
Height

Waist

Hip

Self Dep 1 Dep 2 Dep 3 Dep 4

Does any of the applicant smoke?

If yes, please specify daily consumption.

Does any of the applicant consume alcohol?

If yes, please specify daily consumption.

Does any of the applicant practice any physical exercise?

If yes, please specify which exercise and where.

Section
Section5:
5: Medical History
Medical History
It is compulsory to answer all the questions listed below, if not the application will be considered incomplete.

No in the boxes provided below.

Self Dep 1 Dep 2 Dep 3 Dep 4

1 High Blood Pressure, Vascular Disease and/or Heart Disease

2 Diabetes

3 Malignant Disease of any Kind

4 Lungs Disease and/ or Respiratory System Conditions

5 Liver and/ or Digestive System Conditions

6 Kidneys and/ or Bladder Conditions

7 Sexually Transmissible Disease

8 Reproductive System Conditions (Male & Female)

Eagle Insurance Limited c/o Medscheme T: +230 460 9208

BRN: C06002277 1st Floor, Tower A , 1Cybercity E: health@eagle.mu
eagle.mu Ebene , Mauritius
Eagle Insurance

Administered by A member of IBL

 MEMBERSHIP APPLICATION FORM

Self Dep 1 Dep 2 Dep 3 Dep 4

9 Nervous System

10 Breast Problems

11 Dental System

12 Eye, Ear, Nose and/or Throat

13 Intervertebral Disease
Have any of the applicants been treated and/ or admitted as an Inpa-
14
tient in a Clinic and/or Hospital?
Have any of the applicants been advised to follow in the future a
15

Are any of the applicants currently pregnant? If so, please provide the
16
expected date of delivery.
17 Any other Diseases/Illnesses/Conditions not mentioned above
Any other Illnesses, Disabilities, and/or Accidents lasting more than 15
18
days during the past 2 years

Please give full particulars together with a copy of medical reports available if any of the answers to nos. 1 – 16 above is a Yes.

Nature of Illness/ Date of First

Question No. Name Attending Doctor Duration
Condition/ Injury Occurrence

Section6:
Section 6: Other
Other Insurance
InsuranceCovers
Covers
Do you or any of your dependants have one of the following covers:

Other Medical Insurance. Yes No

If yes, please provide Full Details:

Insured Name:

Name of Insurer:

Amount Covered:

Eagle Insurance Limited c/o Medscheme T: +230 460 9208

BRN: C06002277 1st Floor, Tower A , 1Cybercity E: health@eagle.mu
eagle.mu Ebene , Mauritius
Eagle Insurance

Administered by A member of IBL

 MEMBERSHIP APPLICATION FORM

Personal Accident Cover

If yes, please provide Full Details:

Insured Name:

Name of Insurer:

Amount Covered:

Any other Insurance related to Medical?

If yes, please provide Full Details:

Insured Name:

Name of Insurer:

Amount Covered:

Section 7:
I apply for the enrolment with the inclusion of any Dependant listed in Section 3. I declare that the answers and information
given by me in this application form are true and complete and that I have not withheld any information in regard to this
application that ought to be disclosed.
By signing this document, I expressly authorise the scheme to carry out all necessary investigations, have access to any medical
reports, results and any related information for myself (and any dependent covered) without my consent.

Main Member Dep 1 Signature Dep 2 Signature Dep 3 Signature Dep 4 Signature
Signature (If over 18) (If over 18) (If over 18) (If over 18)

Date: D D M M Y Y Y Y

Note:

Membership Application Form .

This form once completed should be sent to: Membership Card: You can use your electronic card on
the mobile application, Medscheme Touch, which can be
EAGLE INSURANCE LIMITED,
c/o Medscheme, 1st Floor, Tower A, downloaded on both the App Store & Google Play Store.
1Cybercity, Ebene A physical card is also available at the unit price of Rs 100.
Please tick this box if you would like to request same.

Eagle Insurance and Medscheme would love to send you great promotional offers and the latest info from Eagle Insurance by email, post,
sms, phone and other electronic means. we’ll always treat your personal details with the utmost care and will never sell them to other
companies for marketing purposes. Please tick the box below if you would not like to hear from us.

Eagle Insurance Limited c/o Medscheme T: +230 460 9208

BRN: C06002277 1st Floor, Tower A , 1Cybercity E: health@eagle.mu
eagle.mu Ebene , Mauritius
Eagle Insurance

Administered by A member of IBL