STANDARD HEALTH INSURANCE CONTRACT
HEALTH INSURANCE APPLICATION FORM
NOTE THE INFORMATION ON THIS FORM IS TREATED AS CONFIDENTIAL
Please check the appropriate boxes:
l Individual Coverage l Group Coverage
l Employed l Unemployed l Self Employed l Retired
Proposed Effective Date of Policy
PART A: Applicant Information
Last First Middle Date of Birth Sex Height Weight Immigration
Month / Day / Year M/F Feet/Inches Lbs/Oz Status
Applicant
Postal Address: Email Address:
Physical Address:
Telephone: Fax:
Next of Kin: Relationship:
Postal Address: Telephone:
STANDARD HEALTH INSURANCE CONTRACT
HEALTH INSURANCE APPLICATION FORM
PART B: Employer Information
Name of Employer: Employer #:
Postal Address: Email Address:
Physical Address:
Telephone: Fax:
PART C: Dependants
Relationship Family Members Names Date of Birth Sex Height Weight Immigration
Last First Middle Month / Day / Year M/F Feet/Inches Lbs/Oz Status
Spouse
Child 1/
Dependent
Offspring
Child 2/
Dependent
Offspring
Child 3/
Dependent
Offspring
Is your spouse employed? l Y / l N. If yes, please provide name of employer:
Are medical benefits available from any other approved insurer to any person listed above (Part A &/or Part C)? l Y / l N.
If yes, please provide name of approved insurer and telephone information:
Approved Insurer: Telephone:
Has any person listed above (Part A &/or Part C) had continuous coverage for a period of not less than one year? l Y/ l N.
If yes, please state the name of the approved insurer:
STANDARD HEALTH INSURANCE CONTRACT
HEALTH INSURANCE APPLICATION FORM
Part D: Medical Questionnaire
Must be completed by all persons
In the last twelve months has any person listed above (Part A &/or Part C) ever been advised to or received medical consultation, care, treatment or taken
medication in relation to any of the following:
1. lY/lN Heart or circulatory system (including but not limited to infarction, heart attack, angina, rheumatic fever, cardiac defect, arrhythmias,
diseases of veins, arteries or valves, stroke) and/or any other symptom regarding circulatory system or heart.
2. lY/lN Sexually transmitted diseases or Acquired Immunodeficiency Syndrome (AIDS) or ARC (AIDS related complex).
3. lY/lN Neurological System (including but not limited to convulsions, epilepsy, paralysis, Multiple Sclerosis, cerebral infarction (stoke),
Alzheimer’s disease, dementia) and/or any other symptom regarding the neurological system, which if referred to a doctor would result in
a diagnosis.
4. lY/lN Liver disorders (including but not limited to fatty liver, cirrhosis, hepatitis and/or any other symptom regarding the liver, which if referred
to a doctor would result in a diagnosis.
5. lY/lN Kidney/Renal disease or failure.
In the last twelve months has any person listed above (Part A &/or Part C) ever:
6. lY/lN Been treated for Cancer, if yes, please explain:
7. lY/lN Been treated for Diabetes(sugar)/Hypertension(high blood pressure), if yes, please explain:
8. lY/lN Been treated for Respiratory conditions, if yes, please explain:
9. lY/lN Had an organ Transplant, if yes, please explain:
10. l Y / l N Had major surgery, if yes, please explain:
11. lY/lN Are you currently on medications? Please specify.
12. Females only: Are you pregnant, if yes, please specify the number of weeks gestation:
Has any approved insurer within the last twelve months:
13. l Y / l N Declined an application for health insurance?
14. l Y / l N Required an increased premium or imposed special condition?
15. l Y / l N Cancelled or refused to renew an existing health insurance policy
Declaration
I hereby declare that the answers given and recorded herein are, to the best of my/our knowledge, complete and true as at this date.
I hereby authorize any registered medical practitioner, healthcare facility or approved insurer which has records of my health records to release such
information to ________________________________ (name of approved insurer). A photocopy of this signed authorization shall be as valid as the original.
I understand and agree that any injury that occurred within twelve months before the date of this application or any sickness, the signs of which first
appeared on or before the date of this application, are not covered by this contract unless fully disclosed on this application. Failure to disclose such
information could result in denial of a claim and the cancellation of coverage.
I understand and agree that coverage shall not become effective until approved by the approved insurer.
I understand that any changes in my health status after submission of application and prior to approval of coverage must be reported to the approved insurer.
Signature of Applicant: Signature of Dependent (if applicable)
Date: (Month / Day / Year)
THIS APPLICATION WILL BE VALID FOR 3O DAYS FROM THE DATE OF SIGNATURE.
For Official Use Only
Comments from Approved Insurer
FAILURE TO DISCLOSE RELEVANT DETAILS OR GIVING MISLEADING INFORMATION MAY CAUSE YOUR APPLICATION TO BE DEEMED NULL AND VOID.
