PRIVATE HEALTH PROTECT
APPLICATION FORM (A)
MEMBER ADDITION (A)
MEDICAL QUESTIONNAIRE FOR PRIVATE HEALTH PROTECT PLANS ONLY
Member #1 Member #2 Member #3 Member #4 Member #5 Member #6 Member #7
(CHIEF)
1. Has any of the member ever suffered and/or been
Tick the right answer: Y for Yes and N for No
diagnosed with? (ques�on refers to A, B, C, D below)
A. Any form of cancer, carcinoma, leukemia? Y ✔N Y N Y N Y N Y N Y N Y N
B. Coronary disease, heart disease, stroke, diabetes? Y ✔N Y N Y N Y N Y N Y N Y N
C. Sclerosis, SLE (Lupus), chronic obstruc�ve
Y ✔N Y N Y N Y N Y N Y N Y N
pulmonary disease (COPD) or brain tumor
D. Major organ failure or disease
Y ✔N Y N Y N Y N Y N Y N Y N
(Heart, Lung, Kidney, Liver, Pancreas)
2. Has any of the member been treated or
advised to undergo organ transplant Y ✔N Y N Y N Y N Y N Y N Y N
(Bone Marrow, Heart, Lung, Kidney, Liver)?
Please note that a Yes answer (Y) above will lead to rejec�on of applica�on for the concerned member.
If there are more than 7 members in the applica�on, please a�ach an addi�onal form.
INSURANCE TRANSFER ONLY
1. Have you been con�nuously insured for at least 3 years
(no break-in-cover in 3 years) under one similar interna�onal ✔Y N Y N Y N Y N Y N Y N Y N
Health Insurance plan (proof of reference required)
2. Do you cer�fy there is not any �me gap of coverage
✔Y N Y N Y N Y N Y N Y N Y N
between the previous Health Insurance plan and Us?
3. Do you cer�fy you do not have any PLANNED or PENDING
✔Y N Y N Y N Y N Y N Y N Y N
surgery or Hospitaliza�on at this �me of -transfer of insurance-?
Please clarify the exclusion of your current Health
Insurance plan (Previous cer�ficates of insurance required)
Please note that a ''No'' answer (N) above will lead to rejec�on of INSURANCE TRANSFER applica�on for the concerned member.
POLICYHOLDER OR CHIEF OF COMMUNITY PARTICULARS
FULL NAME: ZHANGKAIXUAN
FEMALE ✔ MALE NATIONALITY: China IDENTIFICATION TYPE:
✔ SINGLE MARRIED WIDOW DATE OF BIRTH: 20-10-2002 IDENTIFICATION NO.:
PERMANENT ADDRESS: GVM3+PGH
(Please provide full address)
TELEPHONE NO.: MOBILE NO.: 010748952
EMAIL:
[email protected] OCCUPATION: SELF EMPLOYED HEIGHT (CM): 175cm WEIGHT (KG):
Please provide details of the doctor you most frequently used, if any:
NAME OF CLINIC / HOSPITAL:
NAME AND OFFICE ADDRESS OF THE DOCTOR:
Please provide details of other personal or group health insurance policies you have subscribed, if any:
NAME OF INSURER AND POLICY:
DESCRIBE COVER PLAN:
POLICYHOLDER OR CHIEF OF COMMUNITY PARTICULARS (MEMBER ADDITION ONLY)
POLICY NO.:
FULL NAME:
COMMENCEMENT DATE:
TOTAL OF NEW MEMBERS:
(DD/MM/YY)
PHP-AFAM/V1-10-2022
PRIVATE HEALTH PROTECT
APPLICATION FORM (A)
MEMBER ADDITION (A)
KEY PRODUCT FEATURES
COVERS: - This product is primarily designed to cover hospital and surgical treatment.
- The plans under the label “Personal Accident Protect” cover only treatment arising from accident.
- The plans under the label “Private Health Protect” cover treatment arising from illness and accident.
DOES NOT - This product does not cover out-pa�ent primary care whether given by a Specialist or a General Prac��oner.
- This product does not cover rou�ne dental care.
COVER: - This product does not cover preventa�ve treatment including health check-ups.
- This product does not cover medical condi�ons which were exis�ng, Pre-Exis�ng Condi�ons, before
the policy commencement date. This exclusion is waived a�er three consecu�ve years of cover.
OTHER: - This product is annually renewable. Premiums are not guaranteed and are likely to change with a�ained age every year.
- This product requires the insured to bear a co-payment for all treatment claimed, subject to a maximum
out of pocket in the hospital network, as shown in the benefit table.
- A list of medical condi�ons are excluded during the first twenty four (24 months) months of cover. Refer to policy wording.
- You can upgrade your level of cover, but only at policy anniversary. Upgrade is subject to sa�sfactory individual
health declara�on.
- A list of severe condi�ons are covered only par�ally if diagnosed during the first six 6 months from the policy
commencement date.
- All defini�ons, terms and condi�ons are included in the policy wording.
CHOOSE YOUR PLAN
PERSONAL ACCIDENT PROTECT PRIVATE HEALTH PROTECT
Basic Standard Deluxe Premium Basic Standard Standard+ Deluxe Premium
CHOOSE YOUR PAYMENT OPTION
3 Instalments
One �me Off First instalment (35%) is due on commencement date.
Second instalment (35%) is due a�er 3 months.
Third instalment (30%) is due a�er 6 months. 2% addi�onal premium apply.
WHEN TO START
TOTAL NO. OF MEMBERS INCLUDED EXPECTED COMMENCEMENT DATE
IN THIS APPLICATION DD/MM/YY
ACKNOWLEDGMENT
I/WE DECLARE: - That the answers provided in this Form A and in the accompanying Form(s) B are complete and true
at the �me of applica�on.
I/WE AGREE: - That the informa�on provided shall form the basis of the contract of insurance (Policy).
- To authorize any physicians, hospitals, or any person(s) who a�ended to us, examined us, or is authorized
to maintain a medical record, to disclose any informa�on with regards to any illness, injury or treatment
to FORTE or FORTE’S partner managing claim on FORTE’S behalf, for the purpose of a claim enquiry.
- There won’t be any refund of premium if any claim is made on our policy.
I/WE - That this policy cannot cover a child below 6 years old on standalone basis.
- That this policy shall only be effec�ve subject to approval by FORTE and payment of any premium due.
UNDERSTAND: - That no liability will be accepted un�l full payment is received by FORTE.
- That the policy may be terminated if FORTE discovers that this applica�on contains any false informa�on.
Date:
Signature of the Policyholder or Chief of Community (for and on behalf of all the members of the community)
Agent/ Intermediate/ Broker
I hereby cer�fy that I have duly explained to the -Policyholder or Chief of Community-: the Key Benefits, Terms and Condi�ons and Major Exclusions of this product.
Full name: Date:
Signature of the Agent/ Intermediate/ Broker
PHP-AFAM/V1-10-2022
PRIVATE HEALTH PROTECT
APPLICATION FORM (B)
MEMBER ADDITION (B)
INFORMATION OF MEMBER #2
MEMBER NO.: RELATIONSHIP TO CHIEF OF COMMUNITY:
FULL NAME:
FEMALE MALE NATIONALITY: IDENTIFICATION TYPE:
SINGLE MARRIED WIDOW DATE OF BIRTH: IDENTIFICATION NO.:
MOBILE NO.: EMAIL:
INFORMATION OF MEMBER #3
MEMBER NO.: RELATIONSHIP TO CHIEF OF COMMUNITY:
FULL NAME:
FEMALE MALE NATIONALITY: IDENTIFICATION TYPE:
SINGLE MARRIED WIDOW DATE OF BIRTH: IDENTIFICATION NO.:
MOBILE NO.: EMAIL:
INFORMATION OF MEMBER #4
MEMBER NO.: RELATIONSHIP TO CHIEF OF COMMUNITY:
FULL NAME:
FEMALE MALE NATIONALITY: IDENTIFICATION TYPE:
SINGLE MARRIED WIDOW DATE OF BIRTH: IDENTIFICATION NO.:
MOBILE NO.: EMAIL:
INFORMATION OF MEMBER #5
MEMBER NO.: RELATIONSHIP TO CHIEF OF COMMUNITY:
FULL NAME:
FEMALE MALE NATIONALITY: IDENTIFICATION TYPE:
SINGLE MARRIED WIDOW DATE OF BIRTH: IDENTIFICATION NO.:
MOBILE NO.: EMAIL:
INFORMATION OF MEMBER #6
MEMBER NO.: RELATIONSHIP TO CHIEF OF COMMUNITY:
FULL NAME:
FEMALE MALE NATIONALITY: IDENTIFICATION TYPE:
SINGLE MARRIED WIDOW DATE OF BIRTH: IDENTIFICATION NO.:
MOBILE NO.: EMAIL:
INFORMATION OF MEMBER #7
MEMBER NO.: RELATIONSHIP TO CHIEF OF COMMUNITY:
FULL NAME:
FEMALE MALE NATIONALITY: IDENTIFICATION TYPE:
SINGLE MARRIED WIDOW DATE OF BIRTH: IDENTIFICATION NO.:
MOBILE NO.: EMAIL:
PHP-AFAM/V1-10-2022
