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Self-Health Statement Format (Dependent)

This document is a Self Health Statement form from MetLife for group insurance, to be completed by a dependent or employee. It includes personal information, health history questions, and declarations regarding the accuracy of the provided information. The form requires signatures from both the employee and the dependent, as well as the employer's seal and signature.

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16 views1 page

Self-Health Statement Format (Dependent)

This document is a Self Health Statement form from MetLife for group insurance, to be completed by a dependent or employee. It includes personal information, health history questions, and declarations regarding the accuracy of the provided information. The form requires signatures from both the employee and the dependent, as well as the employer's seal and signature.

Uploaded by

sumaya.misti
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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MetLife

American Life Insurance Company


Met Life Building, 18-20 Motijheel C.A. Self Health Statement
Dhaka-1000,Bangladesh
Phone: (880-2) 9561791,Fax: (880-2) 9558682
Email: [email protected]
Group Insurance

To be Completed by Dependent or Employee on behalf of the Dependent


I Policy No ......................................................

1. Name of. 3. Address


Dependent

2. Name of 4. Relationship
Employee

5. Sex: MaieD Female D 6. Date of I I I I I I I I I 7. Place of


Birth Birth
D D M M Y Y Y Y

8. Height D ft·D inch OR D cm. 9. Weight


I I Ibs OR
I I kgs 10. Occupation

11. Have you, at any time, been treated for or been told that you had any trouble with any of the following?
(Answer each item "yes" or "no" in space [ 1 provided)

Yes No Yes No Yes No


Heart 0 0 Lungs 0 0 Urinary System 0 0
Tumors 0 0 Diabetes 0 0 Nervous Disorders 0 0
High Blood Pressure 0 0 Kidneys 0 0 Stomach or Intestines 0 0
Cancer 0 0 Back or Joints 0 0 Hernia 0 0

Answer each of the following questions (12-20) "Yes" or "No" in the space [ 1 provided Yes No

12. Have you been a patient in a hospital or similar institution during the past three years? 0 0
13. Have you been examined by, or consulted a doctor during the past three years? 0 0
14. Have you been advised to enter a hospital or other institution for diagnosis, rest or treatment but did not do so? 0 0
15. Have you been advised to have a surgical operation or procedure but did not do so? 0 0
16. Have you any known physical impairments, deformities, or ill health not covered in 11-15? 0 0
17. If female, are you pregnant? 0 0
18. Have you ever had an application for or reinstatement of Life, Accident or Health insurance declined, postponed, rated
or in any way modified? 0 0

19. Do you intend to seek medical advice, treatment, or have any medical tests performed? 0 0

20. Acquired Immune Deficiency Syndrome (AIDS) Related Questions. Describe in detail any affirmative answers. Yes No
a. Have you received medical advice, or treatment, in connection with AIDS or an AIDS related condition or
a sexually transmitted disease? Have you been told you had AIDS or AIDS related complex? Have you had or been 0 0
told you had a positive blood test for antibodies to the AIDS virus?
(Human Immune Deficiency Virus)

b. Do you have any of the following which are unexplained: Fatigue, Weight Loss, Diarrhoea, Enlarged Lymph
0 0
Nodes, or Unusual Skin Lesions?

If you have answered "Yes" to any of the above questions 11-20 (a & b) explain in full below:

Indicate the Question No. when answering.

I hereby declare that all statements and all answers to the above questions are complete and true and they are the basis on which insurance is requested ~nder
the Group Policy. I hereby authorize any doctor or other practitioner and any hospital or sanitarium to give the American Life Insurance Company (Met Life) any
information it requests about me with reference to any treatments, examinations, advice or hospitalization.

Date Signature of Employee Signature or Thumb Print of Dependent

Seal & Signature of Employer Name of Policyholder

G-42

American Life Insurance Company is incorporated in the USA as a Limited Company

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