M & M Insurance Broking Services LimitedLeading in Ideas and Service

New Enrolment Application

Referred By

Name

Address

Sex Male
Female

Date of Birth

Place of Birth

Plan INDVS

Do you have any other medical coverage? Yes No

Insurance Company

Name of Plan

Coverage Option

Primary

Secondary Top Up Criticare

Height

Weight

Occupation

Landline Phone

Mobile Phone

Other Phone

Confirm Email

Please enter 1 of the following

National ID #

National ID Expiry Date

Driver's Permit #

Driver's Permit Expiry Date

Passport #

Passport Expiry Date

Health Questionnaire

1) Have you at any time been treated for or been told you had any trouble with any of the following?

Heart Yes No

Lungs Yes No

Urinary System Yes No

Tumors Yes No

Diabetes Yes No

Nervous Disorders Yes No

High Blood Pressure Yes No

Kidneys Yes No

Stomach/Intestines Yes No

Cancer Yes No

Back/Joints Yes No

Hernia Yes No

Please give details below including name and address of attending physician(s) and dates attended.

2) Have you been a patient in a hospital or similar instituition during the past three years? Yes No

Please give details below including name and address of attending physician(s) and dates attended.

3) Have you been examined by, or consulted a doctor during the past three years? Yes No

Please give details below including name and address of attending physician(s) and dates attended.

4) Have you been advised to enter hospital or other institution for diagnosis, rest or treatment but did not do so? Yes No

Please give details below including name and address of attending physician(s) and dates attended.

5) Have you been advised to do a surgical operation or procedure but did not do so? Yes No

Please give details below including name and address of attending physician(s) and dates attended.

6) Have you any known physical impairments, deformities or ill health not covered in previous questions? Yes No

Please give details below including name and address of attending physician(s) and dates attended.

7) If female, are you pregnant? Yes No

Please give details below including name and address of attending physician(s) and dates attended.

8) Have you ever had an application for reinstatement of life accident or Health Insurance declined, postponed, rated or any way modified? Yes No

Please give details below including name and address of attending physician(s) and dates attended.

9) Do you intend to seek medical advice, treatment, or have any medical tests performed? Yes No

Please give details below including name and address of attending physician(s) and dates attended.

Dependents

Spouse:
- Includes husband or wife of member through legal marriage or common law marriage. A copy of the marriage certificate is required as proof of dependence. Please note, only 1 spouse is permitted.
Children up to the age 19, or, up to the age of 23 if enrolled full time in tertiary level schooling.
- Biological. A copy of their birth certificate is required as proof of dependence.
- Step children/ adopted children. Any necessary documentation to show legal guardianship.

You can add up to 7 dependents. Complete each dependent's information and health questionnaire before adding another.

Dependent 1

1) Has the dependent at any time been treated for or been told they had any trouble with any of the following?

Heart Yes No

Lungs Yes No

Urinary System Yes No

Tumors Yes No

Diabetes Yes No

Nervous Disorders Yes No

High Blood Pressure Yes No

Kidneys Yes No

Stomach/Intestines Yes No

Cancer Yes No

Back/Joints Yes No

Hernia Yes No

Please give details below including name and address of attending physician(s) and dates attended.

2) Has the dependent been a patient in a hospital or similar instituition during the past three years? Yes No

Please give details below including name and address of attending physician(s) and dates attended.

3) Has the dependent been examined by, or consulted a doctor during the past three years? Yes No

Please give details below including name and address of attending physician(s) and dates attended.

4) Has the dependent been advised to enter hospital or other institution for diagnosis, rest or treatment but did not do so? Yes No

Please give details below including name and address of attending physician(s) and dates attended.

5) Has the dependent been advised to do a surgical operation or procedure but did not do so? Yes No

Please give details below including name and address of attending physician(s) and dates attended.

6) Does the dependent have any known physical impairments, deformities or ill health not covered in previous questions? Yes No

Please give details below including name and address of attending physician(s) and dates attended.

7) If female, is the dependent pregnant? Yes No

Please give details below including name and address of attending physician(s) and dates attended.

8) Has the dependent ever had an application for reinstatement of life accident or Health Insurance declined, postponed, rated or any way modified? Yes No

Please give details below including name and address of attending physician(s) and dates attended.

9) Does the dependent intend to seek medical advice, treatment, or have any medical tests performed? Yes No

Please give details below including name and address of attending physician(s) and dates attended.

Dependent 2