PROPOSAL FORM

MEDICAL INSURANCE
Agency:

Code:

Date:

1. Personal Details of Applicant

Title: Mr. / Mrs. / Miss:
Surname:

Names:

Date of Birth:
Height:

ID Number:
m

cm

| | | | | | | |

Weight:

| | | | | |

Kg

Postal Address:
Nationality:

Country of residence:

Name of Employer:

Occupation:

E-mail:

Tel:

Mobile:

2. Details of Persons to be covered in addition to Applicant

1. Name:

Occupation:

I D: | | | | | | | | | | | | | | |

DOB:

Relationship to applicant: Spouse

Son

Daughter

Height:
Other

2 Name:

Occupation:

I D: | | | | | | | | | | | | | | |

DOB:

Relationship to applicant: Spouse

Son

Daughter

Kg

cm. Weight:

Kg

Specify:

Height:
Other

cm. Weight:

Specify:

3. Name:______________________________

Occupation:_____________________________________

I D: | | | | | | | | | | | | | | |

DOB:

Relationship
to applicant:
3. Plan and
SchemeSpouse

Son

4. Name: ____________________________

Daughter

Son

Other

cm. Weight:

Kg

Specify:

Occupation: __________________________

I D: | | | | | | | | | | | | | | |
Relationship to applicant: Spouse

Height:

DOB: ______________ Height:___________

Daughter

Other

cm. Weight: ___________ Kg

Specify: __________________________________

3. Plan Selection
Plan
CLASSIC
GOLD
PLATINUM
a.

PROPOSAL FORM
MEDICAL INSURANCE
(Choose one of the following plans and note that the Applicant plan cannot be lower than the dependents)

Applicant
I
II
III
A

B
E

Spouse
I
II
III
A

B
E

1st Dependent
I
II
III

2nd Dependent 3rd Dependent

I
II
III
I
II
III

Are any of the persons to be covered already or was previously insured under another medical
scheme?
If yes please give details and submit claims history for last 2 years:

b.

Have you or any of the persons to be covered ever been denied, postponed or received quotation
for medical insurance at special terms and conditions including increase in premium? If Yes,
please give details

4. Medical Information
Please answer the following questions by YES or NO as they apply to each of the persons named.
NOTE: Any Pre-Existing Condition not disclosed at Proposal will invalidate claims directly or indirectly relating to it
A. Have any of the named persons ever been diagnosed with or
received treatment or advice for any condition or illness relating
to one of the following categories listed below?
Indicate specific condition by underlining the specific condition.
e.g. cardiac murmurs, high blood pressure, chest pain,
A1. HEART,
tightness of chest, palpitations, coronary circulatory
BLOOD VESSELS,
system thrombosis, valve defects, shortness of breath,
OR
stroke, diabetes, high cholesterol, cramps during light
CIRCULATORY
exercise, or walking, varicose veins, cardiac
SYSTEM
irregularities, swelling of the legs, or leg ulcers
A2.RESPIRATORY
SYSTEM OR
LUNGS
A3. DIGESTIVE
SYSTEM OR
LIVER

A4. KIDNEYS OR
BLADDER
A5. NERVOUS
SYSTEM

A6. EYE, EAR,

NOSE OR
THROAT
A7. SKELETON,
VERTEBRAL
COLUMN,
JOINTS,
MUSCLES, OR
SKIN

e.g. asthma, tuberculosis, chronic bronchitis, pneumonia,

persistent cough, coughing up blood, emphysema/COPD
or bronchospasm
e.g. gastritis, ulcers of the stomach or duodenum,
chronic indigestion, jaundice, liver disease, hepatitis B,
bleeding from the rectum, any related hernia, ulcerative
colitis, gall stones, heartburn, persistent abdominal
pain, unexplained loss of weight, persistent diarrhoea, or
persistent constipation
e.g. kidney stones, infections, blood or protein in the
urine, difficulty in passing urine or urological condition
e.g. depression, anorexia, anxiety or stress-related
disorders, nervous tension, sleep disorders, frequent
headaches, psychological disturbances, migraine, fits,
fainting, blackouts, multiple sclerosis, epilepsy,
paralysis, brain impairment, Alzheimer, or dizziness
e.g. defective sight, glaucoma, retinitis pigmentosa,
hearing impairment, recurrent ear infections, balance
disturbance, vocal problems, impaired speech, allergies,
cataracts, chronic sinusitis, and/or strabismus
e.g. back pain, displacement, of the vertebrae or discs,
any other back or neck trouble or operations, arthritis or
arthritic pain, chronic gout, rheumatism. Eruptions or
diseases of the skin, psoriasis, dermatitis, acne-vulgaris,
nodular cystic or eczema. Any physical disability, any
chiropractic treatment or sciatica.

Applicant

Spouse

1st
Dependent

2nd
Dependent

3rd
Dependent

PROPOSAL FORM
MEDICAL INSURANCE
A8.REPRODUCTI
VE SYSTEM
(MALE &
FEMALE)
A9. BREAST

e.g. ovarian cysts, hysterectomy, venereal diseases,

urinary tract infection, any condition of the cervix,
prostatitis, testicular tumors, endometriosis, fertility
treatment, prosthetic hypertrophy or prostatitis,
undescended testis or phimosis
e.g. lump in breast, breast cancer, symptomatic
excessive enlargement/ reduction of breast.

B1. Have you ever been treated as an in-patient in a clinic/hospital?

B2. Has any medical practitioner been consulted and / or provided
prescriptions for any drugs or medication within the last 24 months?
B3. Does any chronic/long-term medical condition exist or is there any
other known disability, abnormality or recurrent illness or injury?
B4. Are you receiving any treatment for a medical or other problem?
B5. Are you currently taking any prescribed medication?
B6. Have you been abroad for medical treatment, surgery or follow up?
B7. Do you have any impaired vision, Glaucoma, Retinopathy or other
eye condition or are you wearing corrective lenses (glasses, contact
lenses or implants)?
B8. Is there any incomplete dental treatment, dental implants,
orthodontic treatment, dentures, wisdom teeth problems or are you
expecting to receive any dental treatment?
B9. Is there any known or foreseeable need to consult a medical
practitioner, dentist and/or optometrist?
B10. Are you aware of any reason that will require you to be treated as
an in-patient in a clinic/hospital?
B11. Are you pregnant or do you suspect you are?
B12. Are you a smoker and/or do you consume alcohol?
If YES, state how many cigarettes per week and/or pegs per week?

B13. The above questions are not all inclusive. Should any named person have any condition that is not covered by these
questions, please provide such information in the space below:

If any answer to the above questions are YES, please give full details below:
Question
No

Name of Patient

Nature of Medical
Conditions

Treatment & Consultations

received (with Doctors
Name, dates & place)

Further treatment
or consultation
needed

Present state of health

(State if still under
treatment)

2nd Dependent

3rd Dependent

5. Treating Doctor or Family Doctor Details

Details
Drs. NAME
ADDRESS 1:
ADDRESS 2:
TEL 1:
TEL 2:

Applicant

Spouse

1st Dependent

PROPOSAL FORM
MEDICAL INSURANCE

6. Banking Details (For Refund of Claims through Bank Transfer Only)

Bank Name: ______________________________________ Branch: ___________________________________________
Accounts Holder Name: ____________________ Account Number:

Premium Paying Terms:

Mode of Payment:

| | | | | | | |

3 Consecutive months

Bank Standing Order

Cash

| | | | | |

Yearly
Salary Deduction

7. Declaration
I/We, the undersigned, do hereby declare and warrant that all information given in the proposal form,
whether in my/Our handwriting or not, is true and complete.
I/We, agree to be legally responsible for the accuracy of information in the Proposal Form and for
payment of premiums.
I/We, agree that the statements in this proposal shall be the basis of the proposed contract, that any
misstatement or omission of material fact therein may lead to any contract made being declared void
and that in such event all moneys paid in respect thereof shall be forfeited.
I/We, hereby authorize and request any doctor, other person or institution who may be in possession
of, or later acquire any information concerning my/our health, and that of my/our family, to disclose to
SICOM General Insurance Ltd/ Linkham Services Ltd, if required
I/We, agree that cover will commence when the full premium is paid and SICOM General Insurance Ltd/
Linkham Services Ltd have conveyed acceptance of the risk to the applicant or agent as the case may
be.
I/We understand and agree that SICOM General Insurance Ltd/ Linkham Services Ltd have the right to
decline any application without justification
Date:

Signature:
Applicant

Spouse

In accordance with the Data Protection Act 2004, SICOM General Insurance Ltd/Linkham Services Ltd as data controllers will
collect and maintain personal information in order to underwrite and administer the policies of insurance that we issue. All
personal information is treated with the utmost confidentiality and with appropriate levels of security. We will not keep
Your information longer than is necessary.
Your information will be protected from accidental or unauthorised disclosure. We will only reveal Your information if it is
allowed by law, authorised by You, to prevent fraud, or in order that We can liaise with Our agents in the administration of
this policy.
Under the terms of the Act You have the right to ask for a copy of any information We hold on You upon payment of an
administrative fee and to require a correction of any incorrect information held. Any inaccurate or misleading data will be
corrected as soon as possible.

Linkham Services Ltd are the Project Administrator of SICOM MyCare Health Insurance for SICOM General
Insurance Ltd