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Insurance Form For Health

This document contains an individual health insurance application form requesting personal information about the applicant and any dependents, including medical history and current health conditions. It includes a health declaration section asking applicants to disclose any illnesses, injuries, or medical treatments. The final section requires the applicant's signature to authorize the disclosure and exchange of medical information between doctors and the insurer.

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yaserkz1999
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35 views2 pages

Insurance Form For Health

This document contains an individual health insurance application form requesting personal information about the applicant and any dependents, including medical history and current health conditions. It includes a health declaration section asking applicants to disclose any illnesses, injuries, or medical treatments. The final section requires the applicant's signature to authorize the disclosure and exchange of medical information between doctors and the insurer.

Uploaded by

yaserkz1999
Copyright
© © All Rights Reserved
We take content rights seriously. If you suspect this is your content, claim it here.
Available Formats
Download as PDF, TXT or read online on Scribd
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Individual Health Insurance Application Form

A. Applicant Information

Personal Information

Date of birth
Name (First, Middle Initial, Last) Gender Age
Month Day Year

Company Name Dependent of Applicant


Occupation Home Address
Telephone Number Type of Health Plan Gold

Health Declaration
B. The questions below should be answered by applicant on behalf of each of his/ her dependents
(details if answer is yes)

Answers
No Have you ever been diagnosed or treated for:
Yes No

1 Any disorder of the Heart?

2 Any disorder of the Respiratory System?

3 Hypertension, Diabetes, Hyperlipidemia?

4 Cancer or Multiple Sclerosis?

5 Congenital or Hereditary disorders?

6 Hernia, Hemorrhoid, Prostate, Gall Bladder, or Liver?

7 Any disorder of the Ears, Nose or Mouth?

8 Cesarean section, abortion or cyst?

9 Mental or Brain disorders?


10 Any disorder of Kidneys?
11 Any disorder or injury involving the spine and joints?
Do you participate in any hazardous sports? If yes, do you do this activity as a professional
12
sportsman?
13 Are you using regular medication? If yes, please give details of medications.

14 Received medical treatment for any disease, or disorder not mentioned above?
If the reply is YES to any of the questions above please specify the name and write down full details
(preferably by a medical physician) on the opposite page
State the details below where the answer is “yes”

Question
Illness or Injury Medical Details
Number

12

Declaration and Authorization


C. I hereby declare and agree, with this respect both to myself and to my Dependents, that:
1. To the best of my knowledge, the answers given in this proposal and those included in any related statement, or
medical examination that may be required, are true and complete and I fully understand and agree that if the insurer
accepted my Application, it shall form the basis of the proposed policy.

2. The above answers and statements as well as those that are included in any other Application, shall form and integral
part of the Policy.

3. I accept that no indemnity will be paid under the proposed Policy for medical expenses arising from disorders which
were declared prior to the completion of this Application and which were not disclosed to the insurer at the date of this
Application.

Failure to disclose material information to the insurer, should have been known by the undersigned, will invalidate the
proposed policy.

4. I am aware of the general terms of insurance and I accept them.

With the above I authorize my doctor, health institution company, or other organization or person that has and
information about my health and/ or activities (and those e of my Dependents) to provide the Insurer with said
information, which shall include hospital and any other records pertaining to medical advices, diagnosis, treatment, or
disturbances. A photocopy of this authorization has the same validity as the original.

The Insurer is not bound to accept this Application. He is also entitled to request from the applicant medical evidence,
including medical examination at the applicant’s expense, before accepting the Applications.

Withholding any information that could have influenced the Insurer’s decision to accept the application under the
conditions specified shall invalidate the policy.

Date: ………………………
21-June-2022 Applicant’s Signature:
……………………………………

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