Medical Application Form - Fillable Page 2
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3In case the answer is YES to any of the conditions/diseases above please specify full details (preferably by a Medical Physician) on the additional
questionnaire (Personal Information), which will be found attached to this application form.
In case medication is required on a regular basis please specify the full details such as genuine name, brand name and daily/weekly quantity on
.
the additional questionnaire (Personal Information), which will be found attached to this application form
Comments:
Only to be filled out if you have answered “Yes” in the question of any family members, who is not proposed for
Insurance.
I agree that no indemnity will be paid under the proposed insurance policy for medical expenses arising from
disorders which were declared prior to 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 will invalidate the proposed
insurance policy.
I hereby agree, with this in respect to both, myself and my Dependants that I am aware of the general terms of this
insurance and I accept them for myself and on behalf of my dependants. I the undersigned declare that all of the
above information as well as all declarations on the additional questionnaire (personal information) are true and
complete. This information shall be considered as an integral part of the insurance policy.
Date:
Signature:
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Parent category: Business