SUSCRIPTION APPLICATION FORM MAJOR MEDICAL EXPENSE ... · Section B In addition to the diseases...
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Applicant Frequency of Payment New policy Rehabilitation Addition of dependent Change of plan Other Inclusion Annual Biannual Other Address Address Legal Representative Tax ID Number or equivalent Information of the Legal Representative Contracting Party Company name Phone Number Email Email Policy number Age Date of birth Sex mm y y y y d d First name F M ID Number/Passport Middle name Initial Surname Mother’s maiden name Weight Lbs/Kgs Height Feet/Mts. Phone Number Cell phone number Office Number Fax Country of residence City Name of Company where works Occupation/Position City Country Sector Residence Address Subscription Application Form Major Medical Expense Insurance Page 1 of 5 Optimum Plus Optimum Security Advance Option I $1,000 $2,000 $3,000 $5,000 Option II Option III Option IV Plans Deductible
Transcript of SUSCRIPTION APPLICATION FORM MAJOR MEDICAL EXPENSE ... · Section B In addition to the diseases...
Applicant
Frequency of Payment
New policy
Rehabilitation
Addition of dependent
Change of plan
OtherInclusion
Annual Biannual Other
Address
Address
Legal Representative
Tax ID Number or equivalent
Information of the Legal Representative
Contracting Party
Company name
Phone Number
Policy number
Age
Date of birth Sexm m y y y yd d
First name
F M
ID Number/Passport
Middle name Initial Surname
Mother’s maiden name
Weight Lbs/Kgs Height Feet/Mts.
Phone Number
Cell phone number Office Number Fax
Country of residence
City
Name of Company where works Occupation/Position
City
CountrySector
Residence Address
Subscription Application FormMajor Medical Expense Insurance
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Optimum Plus
Optimum
Security
Advance
Option I $1,000
$2,000
$3,000
$5,000
Option II
Option III
Option IV
Plans Deductible
Name of Child
University Phone number
Name of Child
University Phone number
Section A
Subscription Application FormMajor Medical Expense Insurance
Name(s)
Surnames
Name(s)
Surnames
Name(s)
Surnames
Name(s)
Surnames
Feet/Mts.Lbs/Kgs
Feet/Mts.Lbs/Kgs
Feet/Mts.Lbs/Kgs
Child
Spouse
Child
Spouse
Child
Spouse
Child
Spouse
F M
F M
F M
Feet/Mts.Lbs/Kgs
F M
m m y y y yd d
m m y y y yd d
m m y y y yd d
m m y y y yd d
Name of dependantsRelationship with the policyholder Date of birth Weight HeightSex
Are the children from 19 to 24 years old full time students?In case of an affirmative answer, complete the information below.
Yes No
To the best of your acknowledge and understanding, is there any person named in this application who has had any of the following diseases?
Yes No1. Arthritis, neuritis, rheumatism, osteoporosis, lumbago, herniated disk, scoliosis, or other conditions of the dorsal spine or other musculoskeletal disorders?
Yes No2. Embolism, thrombosis, migraine, headaches and other cerebrovascular conditions?
Yes No4. Impaired vision, glaucoma, cataract, otitis, labyrinthitis, impaired hearing or other conditions of the sight and of the ear?
Yes No5. High blood pressure, heart conditions, murmur, valvular heart disease, angina, heart attack, varicose veins, phlebitis, cardiac pathology or other conditions of the Cardiovascular System?
Yes No6. Tuberculosis, emphysema, bronchitis, rhinitis, sinusitis, tonsillitis, asthma, allergies or other conditions of the Respiratory System?
Yes No7. Hiatal hernia, gastroesophageal reflux, gastritis, ulcers, colitis, hepatitis, diverticulosis, hemorrhoids, bowel, rectum, liver, gallbladder, pancreas problems and other conditions of the Digestive System?
Yes No8. Kidney stones, nephritis, urinary infections, blood in the urine, kidney conditions or other conditions of the Urinary System?
Yes No3. Epilepsy, fainting, drowsiness, nervous breakdown, anxiety, depression, seizures or other conditions of the brain or Nervous System?
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Subscription Application FormMajor Medical Expense Insurance
9. Prostate, testicles, varicocele conditions or other conditions of the male reproductive organs? Yes No
13. Prosthetics, implants, amputation, aftermath of some sort of functional limitation? Yes No
Yes No10. Anemia, sickle-cell anemia, hemophilia, clotting disorders, rheumatic fever or other blood conditions?
Yes No11. Diabetes, cholesterol or high triglycerides, thyroid conditions, gout, growth or inflammation of lymph nodes or endo-crine disorders?
Yes No16. Uses or has used psychoactive substances or stimulants?
Yes No17. Sexually transmitted diseases, gonorrhea, syphilis, chlamydia, infection with human papilloma virus, herpes or other?
Yes No18. Has had any disease, condition, sign, accident or physiological disorder, which has not been mentioned in this form?
Yes No20. Abortions, pelvic pain, endometriosis, cysts, any type of mass, cervicitis, breast and ovaries conditions, menstrual disorders, menstrual bleeding, menstrual disturbances or disorders of the reproductive organs?
Yes No
No
No
No
19. Are you pregnant? Indicate weeks of pregnancy
Yes No12. Cancer, tumor, cysts, leukemia? Has received chemotherapy, radiotherapy or alternative treatment? Detail below.
Yes No14. Any deformity, congenital defect or disease, loss of hearing, eye sight or any other member?
Yes No15. Has received blood transfusion? Why?
Section B
In addition to the diseases mentioned in Section A, to your best understanding and acknowledge, is there any person named in this form that:
If you have answered YES in any part of Section A or Section B, complete the following information (If you require additional space for writing, you can give more details in another sheet)
Yes1. Has consulted a doctor for medical or surgical treatment, or for advice for any other disease not mentioned in Section A.
Yes2. Has had any alteration of good health not mentioned in Section A or in the first question of this section.
Yes3. Has had a physical exam.
Name of patient Diagnosis and treatment Date Name and address of hospital
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Name of the company
Insurance Company
Type of Policy
Date of issuance of the policy
Name of Insured
Policy Number
Subscription Application FormMajor Medical Expense Insurance
Name of patient Diagnosis and treatment Date Name and address of hospital
Yes NoHas an insurance company declined, postponed or limited a life, accident or health insurance to you or any of the dependents listed? If you answered yes, name the reason.
A. Worldwide Medical Assurance, Ltd. Corp. (hereinafter: the Company) reserves the right to reject or accept any subscription application. The subscription of this form does not mean the automatic acceptance of the insured. Coverage provided by the Company does not enter into force until the issuance of the policy.
B. You agree that all answers given above are complete and true to your best knowledge and understanding. In case of omission, fraudulent or incomplete answers with respect to the stated in this application responses, the Company may exercise its right to terminate or cancel the contract.
D. This form constitutes the English translation of the original document issued in Spanish by the Company. The insured acknowledges that any doubt, discrepancy or controversy arising between the texts in Spanish and English of this form, it shall prevail the text as indicated in the original version in Spanish of this document.
C. With a photocopy or original of this form, the Applicant authorizes any physician, practitioner, hospital, clinic or other facility, government agency or other medical or medically related person throughout the term of the policy contract to provide the Company all information, including records concerning advice, care or treatment provided to the insured and/or its dependents, without any limitation about information regarding mental illness or drug use or alcohol.
It is understood and agreed that:
Yes NoHave you had or have Medical Expenses/Health Insurances? If yes, please detail below
Yes NoDid you have any claim? If affirmative, specify
m m y y y yd d
DateSignature of Applicant
Signature of AgentName of Agent
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Subscription Application FormMajor Medical Expense Insurance
Additional commentary
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Regulado y Supervisado por la Superintendencia de Seguros y Reaseguros de Panamá. FM-SUS101-14 V. 03-06-19
