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Health Questionnaire Form English

This health insurance questionnaire collects information about an employee and their family members for the purposes of providing group hospitalization coverage. The form collects details like names, dates of birth, contact information, as well as medical history and current health status. The employee must disclose any prior or existing illnesses, injuries, mental health conditions, smoking/drinking habits and pregnancies. They also select a coverage plan and authorize the insurance company to obtain any necessary medical records. The employer signs to confirm employment and coverage start date. The insurance underwriters will then review and make a decision on providing standard or non-standard coverage.

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Ahsan Shafique
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115 views

Health Questionnaire Form English

This health insurance questionnaire collects information about an employee and their family members for the purposes of providing group hospitalization coverage. The form collects details like names, dates of birth, contact information, as well as medical history and current health status. The employee must disclose any prior or existing illnesses, injuries, mental health conditions, smoking/drinking habits and pregnancies. They also select a coverage plan and authorize the insurance company to obtain any necessary medical records. The employer signs to confirm employment and coverage start date. The insurance underwriters will then review and make a decision on providing standard or non-standard coverage.

Uploaded by

Ahsan Shafique
Copyright
© © All Rights Reserved
We take content rights seriously. If you suspect this is your content, claim it here.
Available Formats
Download as PDF, TXT or read online on Scribd
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Adamjee Insurance Company Limited

Health Insurance
Health Questionnaire Form (HQF)

Note: This questionnaire is to be filled by the employee only. Any alteration must be signed by the employee.

Name of Employee (in block letters):


Employer’s Name:
Employee’s CNIC No.: Employee Code No. (if any):
Designation: Joining Date:
Residential Address: Phone No.:

FAMILY MEMBERS TO BE COVERED (please use additional sheets, if necessary).


S/No. Name Relationship Date of Birth Height (Feet) Weight (Pounds)
1 SELF
2
3
4
5
6

(Please read the following questions carefully and answer each question by ticking the appropriate boxes. If the answer to any of the question(s) is
“YES”, then please give full details disclosing the exact diagnosis & attach copies of reports/investigations. If you are in any doubt, then refer to
your physician for the details. Non-disclosure of any fact may invalidate a future claim.)

1) Before applying for insurance, have you or any of your family members (spouse/children/parents): Yes No
a. Suffered from any medical condition/disease/illness/injury? If yes, details Yes No
b. Received any diagnosis from a Doctor/Hakeem or Homeopaath (even if no treatment is provided)?
c. Are any of the members listed above suffering/suffered from any physical deformity ? Yes No
d. Do any of the members listed above have/had any congenital abnormality/birth defect? Yes No
e. Do any of the members listed above suffer or have suffered from any mental, psychiatric or nervous disorders? Yes No
Yes No
2) Do you or any member of your family smoke or consume alcohol? If yes, then how much?
3) Are you or your spouse pregnant? If yes, how many months? Yes No
4) Are you and all members of your family (listed above) in good health? Yes No

PLEASE PROVIDE DETAIL(S) FOR THE QUESTION(S) 1(a) to 1(e) TICKED”YES”.


Name of the person whose answer Name of the Hospital & Attending
has been ticked “Yes” Nature of Illness Medicines Taken Physician Present Status

DECLARATION & AUTHORIZATION: Please mention the plan/category for this employee.
I hereby declare that what has been stated above is true and complete and to the best of my knowledge and belief.
I have not withheld any material information and that it is understood and agreed that this declaration and the A B C D E
application of my employer to the Adamjee Insurance Company Limited are the basis for the Group Hospitalization
Insurance cover applied for, and that any non-disclosure or misrepresentation of facts will make my/our insurance If other, please specify:
since inception. I hereby authorize any hospital, physician, or surgeon who has or may have attended to me or my
family to furnish to Adamjee Insurance Company Limited with any information they may require concerning my/our
medical history or examinations. Coverage Effective Date:

* In ease of spouse addition, kindly provide the


Date of Marriage or copy of the Nika Nama.

Signature of Employee with Date Signature of the Employer Stamp of the Employer
(for self & on behalf of dependants)

FOR THE USE OF ADAMJEE INSURANCE COMPANY LIMITED ONLY

(1) Hospitalization: Standard Non-Standard U/W Comments:

(2) Dread Disease / Major Medical Standard Non-Standard U/W Comments:

(3) Maternity Standard Non-Standard U/W Comments:

Adamjee Insurance Company Limited, Health Insurance Department, 3rd Floor, Tanveer Building, 27 C-III,
M. M. Alam Road, Gulberg-III, Lahore. Webside: www.adamjeeinsurance.com

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