Applicant's Name:

Telephone number:

2 - Plan required:

Applicant's given name:

5 - Personnel Details (you means all persons to be insured)

a - Are you in a good health?
If "No" give full details overleaf
Yes   No

b - Have you consulted a medical practitioner within the last 12 month or been referred to a hospital or specialist within the last 5 years?
Yes    No  

c - Have u been admitted to a hospital, nursing home or other medical facility 
within the last 5 years?
Yes   No

d - Have you diagnosed as having a chronic medical condition such as 
tuberculosis, Aids or Hepatitis?
Yes   No

e - Are there any illnesses, disabilities, defects or related conditions present that may require treatment and which have not already been disclosed?
Yes   No

f - Do you engage in any hazardous sports or activities?
Yes   No

g - Do u live or intend to live in any other country?
Yes   No

If you answered "YES" to any questions 5b - 5g please give the appropriate full details overleaf

6 - Medical and other particulars mentioned in question 4

if your answer to question 5(a) is "No" or any of questions 5(b) to 5(g) is "Yes" then you must provide the following information of each such person:

Name of Person

Date of consultations:

Name of Person

Date of consultations:

7 - Declaration

I/We declare that all the information on this application Form is true and complete, and that all the persons proposed for insurance are in good health and free from physical defect or infirmity, I/We am/are unaware of the existence of any medical condition or circumstance foreseeable requiring my/our hospitalization in the future, and understand that Benefits will not apply to treatment or expense arising from unknown medical conditions or from any illness or condition for which treatment or medication, advice or diagnosis has been sought or received during the two year period prior to my/our enrolment in the Policy. I/We authorize any Doctor who has attended me/us torelease any information the Company may require, and I/We will co-operate fully with the Company and furnish such additional medical evidence as may be required. I/We agree to accept insurance as specified in my/our Policy and Certificate of Insurance, and that this Application and Declaration shall be the basis of the Contract between me/us and the Company. I/We understand this Application will be the subject to approval and acceptance by the Company before cover can be granted, and an additional premium may be charged depending upon job occupation, hazardous sports or remote location.

mode of payment ( the usual one)

Note: we would remind you that you must disclose to us, fully and faithfully, the facts you know or ought to know, otherwise you may not receive any benefit form your policy.