- J W Seagon & Co Ltd

AWS HEALTH PLANS
Application Form
Please complete in BLOCK capitals ensuring all relevant fields are completed.
An incomplete form will delay the processing of your application.
In partnership with
Please tick
Individual
Corporate
If Corporate Application, please write name of the group:
1 Your Personal and Cover Details
Main Applicant (MA)
Title: Mr / Mrs / Miss / Ms / Dr:
First Name(s):
ID. No.
Last Name(s):
Passport No:
Postal Address:
Post Code:
Mobile No:
Home Tel. No:
Business Tel. No:
Email Address:
Country of Residence:
Nationality:
Occupation:
First Language:
Date of Birth: DD/MM/YYYY
Age Last Birthday:
Name of Employer:
Male:
Height:
Female:
cm
feet
Weight:
kg
Smoker: Yes
No
Smoker: Yes
No
Smoker: Yes
No
Smoker: Yes
No
Smoker: Yes
No
Smoker: Yes
No
Your Partner (Spouse) (S)
Title: Mr / Mrs / Miss / Ms / Dr:
First Name(s):
Last Name(s):
Country of Residence:
Nationality:
Occupation
Date of Birth: DD/MM/YYYY
Male:
Female:
Age Last Birthday
Height:
cm
feet
Weight:
kg
1st Dependant (D1) (Under 18 yrs or 24 yrs if attending college and fully dependant upon the parents)
Title: Mr / Mrs / Miss / Ms / Dr:
First Name(s):
Last Name(s):
Nationality:
Date of Birth: DD/MM/YYYY
Male:
Female:
Age Last Birthday:
Height:
cm
feet
Weight:
kg
2nd Dependant (D2)
Title: Mr / Mrs / Miss / Ms / Dr:
First Name(s):
Last Name(s):
Nationality:
Date of Birth: DD/MM/YYYY
Age Last Birthday:
Male:
Female:
Height:
cm
feet
Weight:
kg
3rd Dependant (D3)
Title: Mr / Mrs / Miss / Ms / Dr:
First Name(s):
Last Name(s):
Nationality:
Date of Birth: DD/MM/YYYY
Male:
Female:
Age Last Birthday:
Height:
cm
feet
Weight:
kg
4th Dependant (D4)
Title: Mr / Mrs / Miss / Ms / Dr:
First Name(s):
Last Name(s):
Nationality:
Date of Birth: DD/MM/YYYY
Age Last Birthday:
Male:
Female:
Height:
cm
feet
If you have further dependants, please use another application form.
1
Weight:
kg
Other Health Insurances (if applicable)
2
Do you currently or have you had health cover with any other insurer in the last five years?
Yes
No
Name of insurer:
Policy No:
Name of Plan:
3
Your Doctor
Please give details of your usual physician or a physician with whom you have consulted in the last two years
Name:
Address:
Telephone No:
Email Address:
Fax No:
Your consent to your doctor to disclose medical information.
On behalf of myself and other applicants named on this form, I authorise this doctor to provide J W Seagon & Co Ltd. with any information the
company should ask for in connection with my membership application and any claims (past, present and future).
If any of the family members included on your application form have a different doctor, please give their name and / or address details in the space
provided at the back of this application and confirm that you have done so by ticking this box.
4 Plan
AFRICA PLAN
2
INTERNATIONAL PLAN
Essential Plan
Essential Plan
Balanced Plan
Balanced Plan
Best Plan
Best Plan (Includes Dental)
Optional Dental Plan†
Optional Dental Plan†
Optional Travel Plan
Optional Travel Plan
DEDUCTIBLE OPTION (USD)
DEDUCTIBLE OPTION (GBP)
None
None
240
150
720
450
1440
900
3200
2000
† This benefit can be added to Africa Essential, Balanced and Best and for the International Plan this benefit can be added to Essential and Balanced. It
is automatically included on the International Best Plan. Please note that if the main applicant applies for dental benefit and/or travel, this applies to
all applicants.
5
Commencement Date
DD/MM/YYYY
Cover will only attach upon your acceptance of the underwriters’ terms and conditions.
6
Payment Details
Choice of Currency
GBP
USD
Preferred Billing Frequency
Quarterly*
Semi-Annual**
Annually
I enclose a cheque for USD
(Indicate amount) or GBP
(indicate amount)
Cheques should be made payable to AFRICA WELLNESS SOLUTIONS
*Quarterly Billing will attract premium loading. Please contact us for further details.
**Semi-Annual Billing will attract premium loading. Please contact us for further details.
***Credit card payments will attract premium loading. Please contact us for further details.
2
2
7 Credit or Charge Card Payment Authority
I hereby authorise that the Card Account specified below may be debited with the correct premium due and all subsequent renewal premiums due as
notified by J W Seagon & Co Ltd until I give notice in writing that I wish to terminate this agreement. I understand that J W Seagon & Co Ltd will give 4
weeks notice of renewal and that the premium will vary each year. I understand that J W Seagon & Co Ltd cannot be held liable if my policy is lapsed
should the credit/charge card be declined and I do not respond to requests for alternative methods of payment.
Card No.
Expiry Date DD/MM/YYYY
Cardholder’s name as shown on the card
Signature of cardholder
Address to where bills are sent
I will advise you immediately if the card becomes lost, stolen or if I wish to close my card account or cancel the authority.
Please tick
Mastercard
Visa
American Express
Other
8 Duty of Disclosure
We would like to draw your attention to the following:In addition to providing all basic information necessary to enable us to place the risk, you must ensure that you are complying with your legal duty of
disclosure of all material facts relating to the risk. In particular, you must satisfy yourself as to the accuracy and completeness of the information you
provide to insurers both at inception and throughout the policy term.
In this respect, you must provide all information relating to a risk, whether favourable or not, which would influence the judgement of a prudent
insurer in determining whether he will take the risk, and if so, for what premium and on what terms. If all such information is not disclosed by you, the
insurer has the right to void the contract from its inception, which may lead to claims not being met.
You should keep a copy of the completed application form for your own records.
9
Important Note
Please ensure that prior to entering into this Contract of Insurance you have been provided with, and have read, the terms and conditions that
will apply to you as the Policyholder and any eligible insured person enrolled on this policy. If you do not understand any aspect of the terms and
conditions you should contact Africa Wellness Solutions at the address given in this form before signing this application.
33
10 Confidential Medical History – Part A
Answer the following questions for ALL Applicants listed on this application form.
Please circle YES / NO to each of these questions for each person to be covered
Main
Applicant
(MA)
Name
Partner /
Spouse
(S)
Name
1st
Dependant
(D1)
Name
2nd
Dependant
(D2)
Name
3rd
Dependant
(D3)
Name
4th
Dependant
(D4)
Name
1. Are any medical / surgical / dental consultations and/or procedures
(including X-ray, lab or other testing) recommended, scheduled or
contemplated for any applicant?
YES / NO
YES / NO
YES / NO
YES / NO
YES / NO
YES / NO
2. Has any applicant ever been refused medical or dental insurance, or
ever had a policy postponed, rated or accepted on special terms?
YES / NO
YES / NO
YES / NO
YES / NO
YES / NO
YES / NO
3. Been examined by, consulted with, or received medical treatment
from a physician?
YES / NO
YES / NO
YES / NO
YES / NO
YES / NO
YES / NO
4. Been examined by, consulted with, or received medical treatment
from a medical specialist or consultant?
YES / NO
YES / NO
YES / NO
YES / NO
YES / NO
YES / NO
5. Been confined (stayed overnight) in a hospital, clinic, sanatorium, or
other treatment facility?
YES / NO
YES / NO
YES / NO
YES / NO
YES / NO
YES / NO
6. Been examined by, consulted with, or received treatment for a
mental health condition or psychological illness?
YES / NO
YES / NO
YES / NO
YES / NO
YES / NO
YES / NO
7. Suffered from any medical condition(s) requiring medical supervision,
medication or treatment of any kind?
YES / NO
YES / NO
YES / NO
YES / NO
YES / NO
YES / NO
8. Been informed of abnormalities in laboratory tests performed?
YES / NO
YES / NO
YES / NO
YES / NO
YES / NO
YES / NO
Within the last 4 years has any applicant:
Has any Applicant listed on this application had any disease or impairment of or suffered any symptoms or required any medication, treatment
or hospital consultation(s) for the following:
4
9. AIDS / ARC / HIV
YES / NO
YES / NO
YES / NO
YES / NO
YES / NO
YES / NO
10. Alcohol dependency or drug/substance abuse
YES / NO
YES / NO
YES / NO
YES / NO
YES / NO
YES / NO
11. Anaemia or any blood disorder
YES / NO
YES / NO
YES / NO
YES / NO
YES / NO
YES / NO
12. Arthritis, or any disorder of any muscles or joints
YES / NO
YES / NO
YES / NO
YES / NO
YES / NO
YES / NO
13. Asthma, bronchitis or any other respiratory disorder
YES / NO
YES / NO
YES / NO
YES / NO
YES / NO
YES / NO
14. Back / Spine / Neck
YES / NO
YES / NO
YES / NO
YES / NO
YES / NO
YES / NO
15. Blood pressure / Hypertension
YES / NO
YES / NO
YES / NO
YES / NO
YES / NO
YES / NO
16. Blood Vessels / Clots / Circulatory system
YES / NO
YES / NO
YES / NO
YES / NO
YES / NO
YES / NO
17. Bones (including fractures)
YES / NO
YES / NO
YES / NO
YES / NO
YES / NO
YES / NO
18. Brain / Head
YES / NO
YES / NO
YES / NO
YES / NO
YES / NO
YES / NO
19. Cancer, tumour, growth or cyst
YES / NO
YES / NO
YES / NO
YES / NO
YES / NO
YES / NO
20. Carpal Tunnel Syndrome
YES / NO
YES / NO
YES / NO
YES / NO
YES / NO
YES / NO
21. Cerebrovascular Disease / Disorder or stroke
YES / NO
YES / NO
YES / NO
YES / NO
YES / NO
YES / NO
22. Chest pains, palpitations, heart murmur, angina, heart attack or
any other heart disorder
YES / NO
YES / NO
YES / NO
YES / NO
YES / NO
YES / NO
23. Cystic Fibrosis
YES / NO
YES / NO
YES / NO
YES / NO
YES / NO
YES / NO
24. Dental / Gum Disease
YES / NO
YES / NO
YES / NO
YES / NO
YES / NO
YES / NO
25. Diabetes
YES / NO
YES / NO
YES / NO
YES / NO
YES / NO
YES / NO
26. Ears, eyes, nose or throat
YES / NO
YES / NO
YES / NO
YES / NO
YES / NO
YES / NO
27. Epilepsy, convulsions, seizures, fits
YES / NO
YES / NO
YES / NO
YES / NO
YES / NO
YES / NO
28. Gastrointestinal disorder (Stomach / Intestines)
YES / NO
YES / NO
YES / NO
YES / NO
YES / NO
YES / NO
29. Gout
YES / NO
YES / NO
YES / NO
YES / NO
YES / NO
YES / NO
30. Hernia
YES / NO
YES / NO
YES / NO
YES / NO
YES / NO
YES / NO
31. Immune System Disorder
YES / NO
YES / NO
YES / NO
YES / NO
YES / NO
YES / NO
32. Injury, operation, physical defect or deformity
YES / NO
YES / NO
YES / NO
YES / NO
YES / NO
YES / NO
4
Main
Applicant
(MA)
Name
Partner /
Spouse
(S)
Name
1st
Dependant
(D1)
Name
2nd
Dependant
(D2)
Name
3rd
Dependant
(D3)
Name
4th
Dependant
(D4)
Name
33. Kidney / Bladder / Urinary tract
YES / NO
YES / NO
YES / NO
YES / NO
YES / NO
YES / NO
34. Liver, gall-bladder, pancreas or spleen
YES / NO
YES / NO
YES / NO
YES / NO
YES / NO
YES / NO
35. Mental / Nervous disorder
YES / NO
YES / NO
YES / NO
YES / NO
YES / NO
YES / NO
36. Neurological / Nervous system
YES / NO
YES / NO
YES / NO
YES / NO
YES / NO
YES / NO
37. Paralysis
YES / NO
YES / NO
YES / NO
YES / NO
YES / NO
YES / NO
38. Prostate
YES / NO
YES / NO
YES / NO
YES / NO
YES / NO
YES / NO
39. Rheumatic Fever
YES / NO
YES / NO
YES / NO
YES / NO
YES / NO
YES / NO
40. Reproductive Disorder or Infertility
YES / NO
YES / NO
YES / NO
YES / NO
YES / NO
YES / NO
41. Skin
YES / NO
YES / NO
YES / NO
YES / NO
YES / NO
YES / NO
42. Sleep Disorder
YES / NO
YES / NO
YES / NO
YES / NO
YES / NO
YES / NO
43. Stroke
YES / NO
YES / NO
YES / NO
YES / NO
YES / NO
YES / NO
44. Surgical Operation
YES / NO
YES / NO
YES / NO
YES / NO
YES / NO
YES / NO
45. Ulcer
YES / NO
YES / NO
YES / NO
YES / NO
YES / NO
YES / NO
46. Urinary Abnormality
YES / NO
YES / NO
YES / NO
YES / NO
YES / NO
YES / NO
47. Other medical condition not listed
YES / NO
YES / NO
YES / NO
YES / NO
YES / NO
YES / NO
5
10 Confidential Medical History – Part B (PLEASE USE BLOCK CAPITALS)
1.
2.
3.
4.
5.
6.
Relevant
Question
No. in
Part A
Medical Condition Please
specify name of the illness
or medical condition
Date treatment was
received
Details of the treatment &
consultations
received (Provide medical
reports if available)
Name and address of the
medical practitioner
Current status of medical
condition/Current
treatment
MA
S
D1
6
D2
D3
D4
If there is insufficient space, please use the space provided on this application on page 7 and indicate that you have done so by ticking this box.
6
Do you partake in hazardous pursuits?
YES
NO
(If yes, please give specific details of the sport / activity. Also detail your level of competence, qualifications gained and details of any courses attended).
Any Additional Details
Notes and Declaration
Notes:
•Home Country: this is the country for which you hold a passport
•Country of Residence: this is the country where you are living for the most part of the year
•Elected Country: this is the country of your choice where you would wish to be treated for a major surgical intervention – please see the policy wording for further
details. Please note that your Elected Country:
1. must be within your chosen geographical area of cover
2. will apply to all insured members of your family
3. can be the same as your Home Country.
Declaration
I declare to the best of my knowledge and belief that the statements made by me on this application form, together with any supplementary information forming part
of this application are full, true and correct. I understand that any changes to the information I have provided which take place between the time this form is completed
and the time coverage becomes effective, must be notified in writing to the Insurer prior to the effective date of this coverage and that failure to do so may result in the
rejection of a claim or cancellation of my policy.
Important Note
Please ensure that prior to entering into this Contract of Insurance you have been provided with, and have read, the terms and conditions that will apply to you as the
Policyholder and any eligible insured person enrolled on this policy. If you do not understand any aspect of the terms and conditions you should contact Africa Wellness
Solutions at the address given below before signing this application.
Data Protection Notice
I confirm that International Health Solutions, Europ Assistance Holdings Limited may use my personal information to administer my policy, process claims, for
underwriting and pricing purposes, to maintain management for business analysis and may disclose personal information under the protection of a contract to their
agents or service provides to administer my policy, to those involved with my treatment or care and to any IFA or intermediary appointed to act on my behalf. I confirm
that my data may be processed by service providers in a country outside the European Economic Area. By signing this application form I agree that International Health
Solutions, Europ Assistance Holdings Limited and its agents may use the information I supply which may include health information that the Data Protection 1998 Act
defines as ‘sensitive data’ for the purposes stated.
I confirm that for the purposes of the Act, I have the authority of any member of my family named on this application form to consent on their behalf to their personal
data being processed and by signing this application form I agree that International Health Solutions, Europ Assistance Holdings Limited may use their personal data for
the purposes described above.
Signed by the applicant and on behalf of all other family members included in this application form.
Signature:
Date: DD/MM/YYYY
7
JWSeagon&Co.Ltd
First Floor, Oilibya Plaza, Muthaiga
P.O. Box 16658 00620 Nairobi, Kenya
Tel: +254 (20) 4050008; (0722) 205705
Fax: +254 (20) 4050062 Wireless: (20) 8011006/7/9
Email: [email protected]
JWSeagon&Co. Insurance Brokers (TZ) Ltd.
7th Floor, Amani Place, Ohio Street
P.O. Box 38568 Dar es Salaam, Tanzania
Phone: + 255 (22) 2196830 Mobile: +255 (0688) 750720
Fax: +255 (22) 2123562
Email: [email protected]
You can download this document at:
www.jwseagon.com/downloads
www.jwseagon.com