THE HERITAGE INSURANCE COMPANY KENYA

LIMITED
Liberty House, Processional Way

t 254 20 278 3000

m 0711 039 000, 0734 101 000
f 254 20 272 7800
e
w

Health Cover Membership Application Form

Section A and B to be completed by employee; Section C to be completed by employer.

Employer / Scheme
ETelephone no. (w)
Full names of VERTIV KENYA
employee
Esther Kagure Wanjiku
Telephone no. (h)
Please include country and area code Please include country and area code
Cell phone
Email address
ID number Date of birthD D –M M – GenderM F
Y Y Y Y
PIN
number
Occupatio
n
SECTION B

Dependants to be included under your health insurance cover:

First Name Middle Name Surname Date of birth Gender Relationship to you (Wife, son
etc)

1. M F
D D M M Y Y
M F
2.
D D M M Y Y
3. MMM
FMFFF
D D M M Y Y M F
4.
D D M M Y Y
5.
D D M M Y Y
6.
D D M M Y Y
7.
D D M M Y Y
NB: Please use an additional form if there are more than seven (7) dependants

HEALTH DECLARATION BY EMPLOYEE

PLEASE ANSWER TO THE BEST OF YOUR KNOWLEDGE OR BELIEF

1. a) Name and address of your present doctor

b) Date last consulted (if within last 10 years)

Reason?
c) What treatment was given or medication
prescribed?

Attach 1 recent passport photo for you and each of your dependants (not required for groups on smart cards)

Attach 1 recent passport photo for you and each

HERITAGE HEALTH COVER

Membership Application Form | V05 | 1 of
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* PLEASE NOTE TO COMPLETE PAGE 2 OF THIS FORM

HERITAGE HEALTH COVER

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If the answer to any question is “Yes”, Identify the question number and include diagnosis, dates, duration, degree of recovery or results and names and addresses of all
attending medical practitioners and medical facilities in the space below.

TICK APPLICABLE ITEMS

Yes No

2. Are you or any of your dependants under medical treatment by

diet, medicine or other means?

3. Have you or any of your dependants ever had or sought advice for:
a) Chest pain, high blood pressure, heart murmur, heart or circulation
disorder?
b) Asthma, chronic cough, shortness of breath or lung disorder?
c) Diabetes or sugar in urine?
d) Ulcer, Colitis, liver or digestive disorder?
e) Cancer, tumor or enlarged glands?
f) Anaemia, bleeding or blood disorder?
g) Dizzy or fainting spells, epilepsy, nervous system or mental disorder?
h) Urine, kidney or bladder disorder?
i) Atrhritis or other joint disorder?
j) Any other illness, surgery or injury?
k) Have you, or any of the dependants to be covered, ever been
diagnosed with a congenital condition?

4. Do you or any of your dependants have any of the following which are
unexplained: Fatigue, weight loss, diarrhoea, enlarged lymph nodes or
unusual skin lesions?
5. Have you or any of your dependants within the past 5 years:
a) had any mental or physical disease or disorder not listed above
b) had a check-up, consultation, illness, injury or surgery
c) been a patient in a hospital, clinic, sanotoruim, or other medical
facility?
d) had a electrocardogram, X-ray, other diagonistic test?
e) been advised to have any diagonistic test, hospitalisation, or
surgery which was not completed.
f) had a blood transfusion?
6. Are you or any of the named dependants presently pregnant? If Yes give name

7. Are you or any of your dependants aware of a condition(s) that require medical, surgical, dental or optical treatment
at the present time? If so, give full particulars:

DECLARATION

I hereby declare that the statements in this form are true and complete. I further declare that I have not withheld any material information in
regard to this application that ought to be disclosed to the Insurer. I agree to abide by rules governing the Insurer and further agree that this
declaration and the answers given in this application form shall be the basis of the contract between me and the Insurer.

I consent to the Insurer seeking information from any doctor, hospital or clinic I have consulted or from any Company from whom I have requested
insurance and I hereby authorise the giving of such information.

Employee name: Date: D D – M M –

Y Y Y Y

SECTION C

D D – M M –
Y Y Y Y

D D – M M –
Y Y Y Y
Position in company

HERITAGE HEALTH COVER

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