RETAIL MEDICAL POLICY

J CARE APPLICATION FORM

INSURANCE

The Jubilee Insurance Company of Tanzania Limited

DIRECTIONS:
6th Floor, Amani Place Ohio Street
P.O. Box 20524, Dar Es Salaam
Tel: +255 22 2135/121-124 Fax: +255 22 2135 116 letters.
[email protected]
www.jubileeinsurance.com
photograph of yourself and of each member of your family
Mwanza proposed for insurance.
Nyanza Co-operative Union Building, Kenyatta Road
P.O.Box 10456, Mwanza * Terms and Conditions apply.
Tel: +255 28 2500822 Fax: +255 28 2500238
Email: [email protected]
Mbeya Quality Centre, Shopping Mall
Arusha NBC (1997) Ltd Building , Nyerere Road, Shop No G13C
2nd Floor, NSSF’s Mafao House, Old Moshi Road Karume Avenue, Ground Floor P.O. Box 20524, Dar es Salaam.
P.O. Box 1836, Arusha. P.O. Box 2182, Mbeya. T : +255 22 2135121-4
T : +255 27 2252131/ F : +255 27 2507341. T/F : +255 25 2503172 E : [email protected]
E : [email protected] E : [email protected]
Dodoma Morogoro Tegeta Branch
Zanzibar Ground Floor, ACT Building, Corner of First Floor, Hood Property Building, Kibo Commercial Complex
Hatibu St/ Seventh Road. Ngoto Street. 1st Floor, Plot No 483
P.O. Box 2344, Zanzibar P.O. Box 11027, Dodoma. P.O. Box 190, Morogoro. Block ‘’E’’ Tegeta
Tel: +255 24 2239243 Fax: +255 28 2239242 T : +255 26 2321066 T : +255 23 2613964 Bagamoyo Road, Dar es Salaam
Email: [email protected] F : +255 26 2320167. F : +255 23 2613966. T: +255 22 2926303
E : [email protected] E : [email protected] Email : [email protected]

1. DETAILS OF APPLICANT

Surname Title

First name Other names

ID or Passport No Gender Male Female

Date of birth D DMMY Y Y Y Marital Status

Height (ft) Weight (kg)

Name of employer (if applicable)

Occupation Nationality

CONTACT INFORMATION

Postal address

Physical home address

Home telephone

Cell phone/ Mobile telephone Email

PARTICULARS OF NEXT OF KIN

Name in Full

Relationship ID or PP No.

Telephone No. Postal Address

PARTICULARS OF BENEFICIARY OF PERSONAL ACCIDENT COVER AND/ OR LAST EXPENSE COVER (Optional)

Name in Full

Relationship ID or PP No.

Telephone No. Postal Address

2. DEPENDANT’S DETAILS
Please note children will be eligible for cover from age of 3 months upto 18 years.

Dependant 1

Surname Title

First name Other Names

ID or Passport No Gender Male Female

DOB
D D MM Y Y Y Y Marital Status

Height (ft) Weight (kg)

Relationship to Applicant Occupation

Dependant 2

Surname Title

First name Other Names

ID or Passport No Gender Male Female

DOB
D D MM Y Y Y Y Marital Status

Height (ft) Weight (kg)

Relationship to Applicant Occupation

Dependant 3

Surname Title

First name Other Names

ID or Passport No Gender Male Female

DOB
D D MM Y Y Y Y Marital Status

Height (ft) Weight (kg)

Relationship to Applicant Occupation

Dependant 4

Surname Title

First name Other Names

ID or Passport No Gender Male Female

DOB
D D MM Y Y Y Y Marital Status

Height (ft) Weight (kg)

Relationship to Applicant Occupation

3. PLAN DETAILS

Please tick (√) the plan chosen or required and the riders

Plan Royal Executive Advanced Premier

Inpatient 80,000,000 50,000,000 30,000,000 15,000,000
Outpatient 1,500,000 1,500,000 1,200,000 800,000
Last Expense 1,800,000 1,800,000 900,000 900,000
Maternity 1,200,000 1,000,000 n/a n/a
Personal Accident 8,000,000 8,000,000 8,000,000 8,000,000
Dental 600,000 600,000 400,000 200,000
Optical 600,000 600,000 400,000 200,000

Premium Computation
Premiums (in Tshs)

Inpatient Outpatient Maternity Last expense Personal Evacuation Dental Optical Totals
Accident

Main Member

Spouse

Child I

Child II

Child III

Child IV

Total Premiums

Total Amount

4. DETAILS OF PREVIOUS MEMBERSHIP

Name of Scheme/Plan - Principal Applicant

________________________________________________________________ From: dd/mm/yy To: dd/mm/yy

Name of Scheme/plan – Spouse

________________________________________________________________ From: dd/mm/yy To: dd/mm/yy

Have you or any of your dependants ever been declined, loaded, or had exclusions applied to them by a medical
scheme? Yes/No
If ‘yes’ please provide details _________________________________________________________________________

__________________________________________________________________________________________________

Have you or any of your dependants lodged a claim in the last one year? Yes/No
If ‘yes’ please provide details _________________________________________________________________________
5. CONFIDENTIAL MEDICAL HISTORY

State whether you or any of your dependants have ever been treated or are currently receiving treatment, or expect to
receive treatment for any of the following illnesses including but not limited to:
Applicants are numbered as per section 2. Please indicate Yes or NO in the applicant’s box below. Note the principal applicant is No. 1.
Question No. 1 No. 2 No. 3 No. 4 No. 5 No. 6
1. Blood disorders. e.g. anemia, bleeding disorders, leukemia

2. Cancer, growths or tumors whether benign or malignant

3. Cardiovascular (heart and blood vessels) disorders e.g. high blood pressure,
varicose veins, palpitations, deep vein thrombosis
4. Ear, nose and throat disorders e.g. hearing/speech impairment, ear infections,
sinus problems, nasal/throat surgery, tonsils, adenoids, previous nasal injuries,
upper airway infections, epistaxis
5. Endocrine disorders e.g. diabetes, high cholesterol , thyroid abnormalities
6. Eye related disorders e.g. blindness, glaucoma, eye surgery, , cataracts, lens
implants, refractive and laser surgery
7. Genito-urinary system e.g. Pelvic inflammatory disease prostate problem,
abnormalities of the penis, scrotum. Reproductive system, blood in the urine,
kidney stones, kidney failure, bladder problems, Dialysis,
8. Gastro-intestinal disorders e.g. recurrent indigestion, heartburn, ulcers, hernia,
piles, fissures.
Have you ever had any endoscopic study of the oesophagus, stomach or
colon?
9a. Gynecological and obstetrical disorders e.g. Fibroids, ectopic pregnancy,
caesarian section, Menstrual irregularities. Abnormal pap smear, receiving
hormone treatment. Uterine bleeding, Laparoscopic surgery, Dilatation and
curettage, miscarriages, pregnancy related problems.
9b. Pregnant, if positive, provide expected date of delivery (dd/mm/yy)
10. Musculo-skeletal disorders e.g. arthritis, Back problems, gout, osteoporosis. All
joint problems and fractures
11. Neurological disorders e.g. epilepsy, Stroke. Brain or spinal cord disorders,
Headache, migraine, Paralysis, meningitis
12. Psychological disorders e.g. alcohol or drug dependency, anxiety disorder,
insomnia, depression, stress, attention deficit disorder, post traumatic stress,
attempted suicide,
13. Respiratory disorders e.g. asthma, rhinitis, chronic bronchitis, cigarette smoking
related disorders, tuberculosis, persistent cough, allergies, chronic obstruction
pulmonary disease, shortness of breath.
14. Skin disorders e.g. eczema, melanoma, skin cancer, burns, scars, keloids,
warts
15. State whether you or any of your dependants have received medical advice or
treatment for any tropical disease e.g. leprosy, sleeping sickness, elephantiasis,
bilharzia, yellow fever
16. Have you or any of your dependants ever sought counseling or treatment in
connection with sexual transmitted infection e.g. gonorrhoea, syphilis, herpes
simplex, Chlamydia
17. Have you or any of your dependants ever sought counseling or treatment in
connection with HIV or AIDS infections or tested positive for HIV or AIDS?
18. Do you or any of your dependants have any hereditary disorders, birth defects
or congenital conditions?
19. Do you or any of your dependants have incomplete dental treatment plan,
dental implants, orthodontic treatment, dentures, and wisdom teeth problems or
do you or any of your dependants currently receive, or expect to receive dental
treatment in the next 12 months?
20. Investigations and/or specialized treatment: In and out of hospital
a) Are you or any of your dependants currently undergoing or expect to
undergo investigations for any medical condition and / or symptoms
not yet diagnosed?
b) Are you or any of your dependants currently receiving, or expect to
receive specialized treatment (i.e. chemotherapy, radiotherapy, bone
marrow transplant, mechanical ventilation, oxygen therapy, dialysis,
psychotherapy or counseling?
21a. Are you or any of your dependants on any medication (please indicate in the
table provided below)
21b Do you or any of your dependants expect chronic medication to be prescribed
in the next 12 months?
If you answered YES (number 21 a & b) please supply details below
Applicant Prescribed Medication Diagnosis Date Started/
To Be Started

If you answered YES to any of the questions above, please supply full details below
Q.NO. Applicant Date Diagnosis Treatment Consulting Doctor Physical address/
Telephone Number

(If the space provided is insufficient, please attach additional information to this application.)

6. SURGERY AND HOSPITAL ADMISSIONS

Please supply details of all surgical procedure(s) and ALL HOSPITAL ADMISSIONS that you or any of your dependants
have undergone in the past, and /or details of all planned surgical procedure(s) and ALL HOSPITAL ADMISSIONS that
you or any of your dependants expect to undergo in the future?
Applicant Surgical Procedure/ Hospital Admission Date Diagnosis

(If the space provided is insufficient, please attach additional information to this application.)

N.B: Any misrepresentation or non-disclosure of material or factual information will render all benefits granted by the
scheme null and void. In addition, any payment made due to such actions will be recovered from the member by the
scheme.

7. General Exclusions

1. Expenses incurred as a result of a Member’s participation in:

(a) Naval, military or air force service or operations;
(b) Hazardous sports including but not limited to Winter sports, water sports mountaineering, hunting, polo, racing
on horseback, rugby, league football, motorcycling or motor racing on machines of greater than 125 c.c.;
(c) Riding or driving in any kind of race;
(d) Air travel except as a fare-paying passenger in any aircraft licensed for passenger carrying. Cover shall not in
any event apply to an Member whilst operating, learning to operate or serving as a Member of a crew of any
aircraft or to travel in any aircraft being used for sky-diving, racing, testing or exploration.

2. Expenses directly or indirectly incurred as a result of:

(a) War (“declared or undeclared”), riot, strike and civil commotion;
(b) Intentional self-injury, suicide or attempted suicide (whether sane or insane), venereal disease, Member’s own
criminal act, intoxication, the use of drugs not prescribed by a physician or injury sustained whilst in a state of
insanity, alcoholism or costs resulting from dependency on or abuse of drugs or other addictive substance;
(c) Nervous breakdown, general debility, psychoneurosis, general “overhaul”
(d) Vaccination, or any treatment undertaken or carried out as a preventative measure;
(e) Treatment by chiropractors, acupuncturists and herbalists, stays and/or maintenance or treatment received in
health hydros, nature cure clinics or similar establishments or private beds registered within a nursing home,
sanatoria, convalescent and/or rest homes or ‘cures’ attached to such establishments;
(f) Pregnancy, childbirth, maternity benefits, abortion, miscarriage, ante-or-postnatal care, caesarean operation
 except where purchased subject to twelve months waiting period;
(g) Family planning and fertility treatment e.g. costs of treatment related to infertility and impotence, hormonal
imbalance, hormone replacement therapy (HRT);
(h) Cosmetic or beauty treatment and/or surgery;
(i) Massage
(j) Hearing tests or cost of hearing aids;
(k)
(l) Birth defects, Congenital illness, conditions and illnesses related to genetic disorders;
(m) *Psychiatric illness, mental disorders and/or insanity expenses will be covered up to the applicable sub limit
subject to twelve months waiting period.
(n) Any claim for expenses relating to any contingency arising whilst the Member is outside the territorial limits of
Tanzania, but this limitation shall not apply to any Member temporarily abroad and requiring emergency treatment
for an illness or injury that occurs during the period of travel provided that such period does not exceed six weeks
in any one visit. Travel and accommodation costs are not covered.
(o) Any claim for expenses related to an accident or illness which may have occurred prior to the effective date or
illness occurring within Sixty (30) days of the effective date or to any illness where it was within the knowledge of a
Member that he was suffering from it at the effective date.
(p) Any claim for expenses occasioned by or through or in consequence, directly or indirectly caused by acts of God
(natural causes)
(q) Treatment of obesity and slimming preparations
(r) Epidemics or unknown diseases
(s) Expenses incurred in connection with Examinations for check-up purposes not incidental to diagnosis of a sickness
or accidental bodily injury such as general health examinations, scans of any nature or any other form of disease /
illness prevention.
(t) or not proven to be effective based on established
medical practice
(u) Costs of treatment for, or related to, Menopause, andropause, ageing, puberty and pre-menstrual tension syndrome
(v) *All expenses associated with HIV/AIDS and related conditions (subject to twelve months waiting period)
(w) *Pre-existing and Chronic conditions (subject to twelve months waiting period and full declaration on the
application at policy inception)
(x) * Cancer treatment (subject to twenty four months waiting period)
(aa) * Treatment of Haemorrhoids, Fibroids, Hernia, Adenoidectomy (subject to twenty four months waiting period)
(bb) Organ transplant (subject to twelve months waiting period)
(cc) Any treatment arising from an accident or event because the mem
alcohol or drugs, unless prescribed and taken according to the instructions of a medical practitioner
(dd) Medical expense directly or indirectly resulting from or in connection with any act of terrorism (“declared or
undeclared”), regardless of any other cause contributing concurrently or in any other sequence to the medical
expense
(ee) All expenses in respect of illnesses/conditions that were subject to waiting periods when the member and
dependant joined the scheme

* Upon expiry of the waiting period (s) as indicated above, members will be required to enrol and adhere to Jubilee’s
chronic disease management program. These conditions must be declared at the time of application for a member

t subject to Jubilee’s written acceptance

3.
compensation including NHIF or any other medical plan.
8. DECLARATION

General
1. I, the undersigned member:
1.1. Hereby apply for myself and my dependants to be registered on The Jubilee Insurance Co of Tanzania Ltd, Medical
Scheme (“the Scheme”) and have read, understood and agree to abide by the Rules of the Scheme.
1.2. Warrant that the contents of this application and any other documents which may be required in support thereof
are true, correct and complete, whether recorded in writing by me or by any intermediary on my behalf and,
should there be any change in the state of health or illness suffered by myself or any of my dependants from the
date of signing this application form and the date of acceptance of the risk by the Scheme, notification of such
change will be provided to the Scheme in writing with full details of condition/ailment;
1.3. Understand that the statement and answers provided form the basis of the contracts and any breach of my warranty
or non
disclosure of any information material to the assessment of this application shall render any contracts to which this
appliction relates null and void and all premiums paid shall be forfeited;
1.4. Understand and accept that no benefit will be payable by the Scheme unless they are satisfied as to the validity of
a claim and have received all requirements which they may deem necessary including the results of such medical
examinations and tests that they may require me or my dependants to undertake;
1.5. Consent to the Scheme addressing any requests for information, tests or examinations directly to any dependant
of mine over the age of 18, with same legal consequences as if the request had been addressed to me in my
capacity as a member;
1.6. Acknowledge and accept that the Scheme reserves the right to cancel membership of the Scheme if any due
premium is not paid on the due date; and
1.7. undertake to inform the Scheme within 30 days should the situation change,

Authority
2. Accepting that I am curtailing my and my dependants’ right to privacy but in order to facilitate the assessment of
the risks and the consideration of any claim, I irrevocably authorize;
2.1. The Scheme to obtain from any person, whom I hereby so authorize and direct to give, any information which the
Scheme deems necessary,
2.2. I further authorize and instruct the Scheme and any hospital concerned to give away information relating to myself
and my
dependants to the Medical Case Managers appointed by the Scheme for purpose of ensuring that the members of
the Scheme receive appropriate and necessary medical services while reducing inappropriate care and wastage
of medical resources,
2.3. I understand and accept that the above authorization constitute a partial waiver of my and my dependants’ right to
privacy.

3 I declare that:
3.1. My dependants(s) is/are residing with me,
3.2. I am liable for his/her family care,
3.3. The dependant(s) is/are my immediate family (Must be a blood relative),
3.4. I undertake to repay the Scheme any amount by which claims paid out exceed benefits covered.

Signature of Member …………………………………………… Date …………………………………………….

Signature of Spouse ……………………………………………. Date …………………………………………….

9. INTERMEDIARY/BROKER DETAILS

Full name of Intermediary/Broker ______________________________________________________________________

Telephone Contacts _________________________________________________________________________________

Intermediary/Broker Declaration

I hereby declare that I explained the benefits of this application and that the applicant is aware of the membership terms
and conditions of Jubilee Insurance Company of Tanzania Limited.

Signature of Intermediary/Broker ………………………………. Date ……………………………………………

OFFICIAL USE ONLY

10. POLICY COMMENCEMENT DATE

Commencement Date: Day________ Month___________ Year_________

Subject always to Declaration section of this application form, the commencement date of this Policy will be the date on
which this application is accepted in writing by us. Please note the commencement date can be no more than 30 days
from the date of completion of this application. Under no circumstances will Policies be backdated

Note: Cover is conditional upon full payment of premium and acceptance of your application that is only confirmed
when an acceptance letter is issued to you)