Health Insurance Proposal Form And Medical Questionnaire
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1HEALTH INSURANCE PROPOSAL FORM AND MEDICAL QUESTIONNAIRE
First name
Father's name
Family
Marital Status
Married
Single
Divorced
Widow
Full address of applicant
Phone number(s)
Fixed -
Mobile -
Email -
Class of Insurance
A
B
S
Riders
Amb.
PM
DV
Family
DOB
NSSF
Sex
Height
Weight
Smoking
Name
Nationality
Occupation
yes/no
members
dd-mm-yy
yes/no
M/F
in cm
in kg
Subscriber
Spouse
Child 1
Child 2
Child 3
Child 4
If a dependent of yours is not applying for coverage, please state the reason:
Yes
Yes
No
No
Circulatory or Heart disease (high blood pressure, arrhythmia, murmur, infarction etc.)
1
Respiratory disease or Allergy (asthma, bronchitis, emphysema, pneumonia, tuberculosis etc.)
2
Digestive disease (constipation, diarrhea, hepatitis, ulcers, pancreatitis etc.)
3
Renal or Urinary disease (nephritis, stones, renal colic, albuminuria, hematuria…)
4
Osteo-articular disease, disease of Hip or Vertebral column (scoliosis, rheumatism, slipped disc etc.)
5
Neurological, Cerebral, or Muscular disease (epilepsy, meningitis, aneurysm, paralysis etc.)
6
Endocrinal or Metabolic disease (goiter, nodules, diabetes, cholesterol, gout etc.)
7
Eye, Nose & Throat disease (glaucoma, retinopathy, dizziness, otitis, laryngitis, sinusitis etc.)
8
Blood, Ganglionic or Skin disease (anemia, hemophilia, adenopathy, eczema, herpes, purpura etc.)
9
10 Sexual disease (AIDS, gonorrhea, syphilis etc.)
11 Tumors or Swelling (fibroma, cyst, lipoma, cancer etc.)
12 Any other disease, past or future operation, Accident or Treatment not mentioned above
13
13 Psychical disease (nervous depression, fatigue, insomnia, psychosis etc.)
Psychical disease (nervous depression, fatigue, insomnia, psychosis etc.)
14 For female applicants, are you pregnant? If yes please state the expected due date?
15 Congenital anomalies, Hereditary/Genetic diseases
If you answered Yes to any of the above questions, please give full details here below:
Name
Date
Hospital
Details
#
I authorize my doctor, health institute or other organization or person that has any information about my health and/or activities (and those of my
Dependants) to provide ASSUREX SAL and/or NEXTCARE SAL with the said information. This shall include hospital and any other records pertaining to
medical advice diagnosis and treatment A photocopy of authorization has the same validity as the original
medical
advi
ce, diagnos s, and treatment. A p otocopy of aut orization has t
i
h
h
he
same validity as t
he
origina .
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I declare that above questions are true to the best of my knowledge and belief, that I have disclosed all particulars affecting the assessment of the risk. I
agree that this proposal and declaration shall be the basis of the contract between me and Assurex SAL, in accordance with the Lebanese Code of
Obligations and Contracts, Article 974, Paragraph 2.
/
/
Signature:
Date (dd/mm/yyyy):
Broker Name
Head Office: Beirut Downtown, Bab Idriss, Patriarch Hoayeck str., Assurex bldg.
: (01)982000 → 4 - Fax: (01)982005 P.O. Box: 11-7358 Beirut - - .lb
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