DIABETES. No. Yes. RESPIRATORY DISEASE. No. Yes. HIGH CHOLESTEROL. No. Yes. RENAL DISEASE. No Diabetes. No. Yes. Heart Attack. No. Yes. Kidney Diseases. No …
PERSONAL FORM FOR LIFE
INSURANCE
This form can be completed and e-mailed to us as an attachment directly by
going to File on the menu bar
and then clicking on Send to and then Mail Recipient addressing it to
info@bkiccom
Your attention is drawn to the declaration at the foot of this
form It is important that all sections of this proposal form
should be fully completed even if it is for renewal of or for an
amount additional to an existing insurance You should declare all
conditions even though you have been declared fit You should not
omit to mention investigations where you have been told that the
result is satisfactory Failure to disclose material information
may invalidate the policy
A
| |FULL NAME |
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| |ADDRESS in |
| |Full |
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| | | |
| |TEL Work | |TEL Home |
| | | | |
| | | |/ |
| |HEIGHT | |WEIGHT |
| | | | |
| | Female | |Male |
| |OCCUPATION |
| | |
| | |
| | |
| | |
| |Describe |
| |Clearly |
B MEDICAL
QUESTIONNAIRE
PLEASE GIVE BELOW FULL DETAILS FOR ANY YES ANSWER INCLUDING DATE
AND DURATION OF ANY ILLNESS, TYPE OF TREATMENT, DOCTORS CONSULTED,
AND TYPE OF SPORT USE SEPARATE SHEET IF NECESSARY
| |
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| | |No | |Yes |2 During the 5 past years, have you been |
| | | | | |unable to work for more than 30 consecutive |
| | | | | |days? |
| | | | | | |
| |
| |
|3 Have you ever been treated for or are you under treatment for : |
| | | | | | |
| |
|No | |
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| | |No | |Yes |4 Have you every been seriously injured? |
| | | | | | |
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| | |No | |Yes |5 Did you have a surgical operation or have |
| | | | | |you been advised to have a surgical operation?|
| | | | | | |
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| | |No | |Yes |6 Did you take or are you taking treatment or|
| | | | | |medication for any disease or disorder? |
| | | |
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| | |No | |Yes |7 Do you intend to seek medical advice, |
| | | | | |treatment or have any medical tests performed?|
| | | | | | |
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| | |No | |Yes |8 Have you tested positive for HIV/AIDS or |
| | | | | |you are awaiting the result of such a test? |
| | | | | | |
| | | | | |If yes, please provide details |
| | | | | | |
| |
|
|
| | |No | |Yes |9 Have you tested positive for Hepatitis B or|
| | | | | |C, or you are awaiting the result of such a |
| | | | | |test? |
| | | | | | |
| | | | | |If yes, please provide details |
| | | | | | |
| |
| |
| | |No | |Yes |10 Have you tested positive or treated for |
| | | | | |any sexually transmitted disease or you are |
| | | | | |awaiting the result of such a test? |
| | | | | | |
| | | | | |If yes, please provide details |
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| | | | | |
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| |
| | |No | |Yes |11 Have you smoked any cigarettes within the |
| | | | | |past 12 months? |
| | | | | | |
| | | | | |If yes, state how many |
| | | | | |per day: |
| |
| |
| | |No | |Yes |12 Do you have any defect of the vision or |
| | | | | |hearing? |
| | | | | | |
| | | | | |If yes, state to what extent
|
| | | | | | |
| |
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| | |No | |Yes |13 Do you drink alcohol? |
| | | | | | |
| | | | | |If yes, state type and amount|
| | | | | |per day: |
| |
| |
|14 Have any of your parents, brothers or sisters died or suffered from any of the |
|following before age 65 : |
| | | | | | |
| | |No | |
| | |Please also
indicate at what age| |
| | |this occurred? | |
| |
| |
| | |No | |Yes |15 Do you intend to engage in hazardous |
| | | | | |activity eg scuba diving or fly other than|
| | | | | |as a passenger on scheduled services ? |
| | | | | | |
| |
| |
| | |No | |Yes |16 Has any application for insurance on your |
| | | | | |life life, accident, health been declined, |
| | | | | |postponed or accepted on special terms ? |
| | | | | | |
|
|
| |
|17 Please give the name and address of your usual doctor: |
| |
|___________________________________________________________________________________|
|__________________________________ |
| |
|___________________________________________________________________________________|
|__________________________________ |
| |
|___________________________________________________________________________________|
|__________________________________ |
| |
|___________________________________________________________________________________|
|__________________________________
|
| | | | | | | | | |
DECLARATION
I HEREBY DECLARE THAT I AM IN GOOD HEALTH EXCEPT IF STATED OTHERWISE
IN THE ABOVE STATEMENT
IMPORTANT:
Before signing this declaration, please check that the answers given
in this application are complete and correct An omission or
incorrect answer may invalidate the policy
I declare that this application and declaration together with the
statements made by me are true and correct and that such statements
together with any forms, statements, reports or other information
completed or supplied by me shall form the basis of the contract I
declare that no material fact has been withheld, misstated or
concealed by me
I authorize any doctor, hospital, medical institution to disclose
information related to my physical or mental health, including the
results of any tests to the Insurance company and I agree that this
authorization shall remain in force after my death
Signed:______________________________
Dated:____________________________________
The Company reserves the right to impose special
conditions or refuse
to accept a proposal for insurance
———————–
Source:bkic.com
