PROPOSAL FORM www.eduhealth.

mu

Instructions:
1. Please complete in BLOCK CAPITALS marking the appropriate box(es) with an X
2. This Application Form must be fully completed

Section 1: Details of Main Member

Title: Mr Mrs Ms Others Please specify: ...................................................................................

Member Surname:

Member First Name:

Gender: Male Female

Date of Birth: DD/MM/YYYY

Nationality:

NIC/Passport No.

ID Number: Please provide us with a copy

Educational Institution:

Marital Status:

Residential Address:

Phone Number: Home Office Mobile

Email Address:

Plan Selection: Bronze Silver Gold

Catastrophe Selection: Rs 500,000 Rs 1,000,000 Rs 2,000,000 Rs 3,000,000

Bank Details of Main Member for Claims Refund

Bank Name:

Bank Account Number:

Section 2: Policy Details

Start Date Cover: DD/MM/YYYY

Method of Payment:

Annually (Specify Mode of Payment):

Monthly (Specify Mode of Payment):

PROPOSAL FORM www.eduhealth.mu

Section 3: Dependants to be Covered

You may include:

• Your Spouse/Partner under the age of 65
• Unmarried children between 18 to 25 years old.
(Proof of full- time study should be provided for children between age 21 to 25 years old).
• All members of a family should be on the same option except for catastrophe limit.

Details Dependant 1 Dependant 2 Dependant 3 Dependant 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 Selected (Bronze/

Siver/ Gold)

Catastrophe Limit
(Optional)

Section 4: Adult Members Physical Details

Self Spouse
Weight

Height

Waist

Hip
PROPOSAL FORM www.eduhealth.mu

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.

* For information on physical exercise, please provide requested details for each applicant on a separate sheet and
attach to the Membership Application Form.

Section 5: Medical History

It is compulsory to answer all the questions listed below, if not the application will be considered incomplete.

Have any of the applicants above ever suffered from or been treated for any of the following? Please indicate with (Y)
for Yes or (N) for 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)

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

14
as an Inpatient in a Clinic and/or Hospital?

Have any of the applicants been advised to follow in the

15
future a specific treatment or to undergo operation?

Are any of the applicants currently pregnant? If so, please

16
provide the expected date of delivery.

17 Any other Diseases/Illnesses/Conditions mentioned above

Any other Illnesses, Disabilities, and/or Accidents lasting more

18
than 15 days during the past 2 years
PROPOSAL FORM www.eduhealth.mu

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/ Attending Date of First

Question No. Name Duration
Condition/ Injury Doctor Occurrence

Section 6: Other Insurance 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:

Have you or any persons to be covered ever been denied cover or received quotation for medical/health insurance at
special terms and conditions including increase in premium?

Yes No

If yes, please provide full details:

.............................................................................................................................................................................................................................

.............................................................................................................................................................................................................................

.............................................................................................................................................................................................................................
PROPOSAL FORM www.eduhealth.mu

Section 7: Confirmation of Data Provided and Authorisation

I 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 hereby authorise/ any medical practitioner, 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, if
required.

............................................ ............................................ ............................................ ............................................ ............................................

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)

Note: Completion and submission of the Membership Application Form does not automatically confirm your Membership.
The confirmation of acceptance and underwriting conditions will be forwarded within 14 days from the reception of the
complete Membership Application Form.

This form once completed should be sent to:

Medibroker Ltd
15D, Royal Road
Belle Rose