HTML Preview Medical Insurance Proposal Form page number 1.
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HEALTH INSURANCE PROPOSAL FORM AND MEDICAL
Q
UESTIONNAIRE
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 SRiders Amb. PM DV
Family
members
Name
DOB
dd-mm-yy
Nationality
NSSF
yes/no
Sex
M/F
Height
in cm
Weight
in kg
Smoking
yes/no
Occupation
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
Y
es
No
N
o
1
Circulatory or Heart disease (high blood pressure, arrhythmia, murmur, infarction etc.)
2
Respiratory disease or Allergy (asthma, bronchitis, emphysema, pneumonia, tuberculosis etc.)
3
Digestive disease (constipation, diarrhea, hepatitis, ulcers, pancreatitis etc.)
4
Renal or Urinary disease (nephritis, stones, renal colic, albuminuria, hematuria…)
5
Osteo-articular disease, disease of Hip or Vertebral column (scoliosis, rheumatism, slipped disc etc.)
6
Neurological, Cerebral, or Muscular disease (epilepsy, meningitis, aneurysm, paralysis etc.)
7
Endocrinal or Metabolic disease (goiter, nodules, diabetes, cholesterol, gout etc.)
8
Eye, Nose & Throat disease (glaucoma, retinopathy, dizziness, otitis, laryngitis, sinusitis etc.)
9
Blood, Ganglionic or Skin disease (anemia, hemophilia, adenopathy, eczema, herpes, purpura etc.)
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
Ps
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chical disease
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nervous de
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ression
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fati
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ue
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insomnia
,
p
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chosis etc.
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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
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treatment.
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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 - www.assurex.com.lb - assurex@assurex.com.lb