ENROLMENT / HEALTH DECLARATION FORM

Important Note : Pursuant to Section 25(5) of the Insurance Act and replacement thereof, you are to disclose in this form, fully & faithfully, all the
facts which you know, otherwise the policy issued hereunder may be void.

EMPLOYEE'S INFORMATION

Name of Employee (as in NRIC / Passport No.)

NRIC / Passport No. Date of Birth (ddmmyyyy) Gender Nationality

M / F

Salary Grade Marital Status Height Weight Monthly Salary

S / M m kg S$

Contact No. (Tel or Mobile No.) Email Address Employment Date (ddmmyyyy)

Residential Address

OFFICIAL USE (INSURER)

i) Medical

Policy No. Insured's Effective Date (ddmmyyyy) Outpatient Benefits Hospital & Surgical Benefits

ii) Life

Policy No. Insured's Effective Date (ddmmyyyy) Term Life Sum Assured Personal Accident Sum Assured
S$ S$

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 MEDICAL QUESTIONNAIRE (all questions must be answered) Employee

Q.No Yes No
1 Are you a member of any military force (excluding National Reservist), do you contemplate to engage, or the past 5 years, have you engaged in any private flying or
hazardous sports or races or flying other than as a fare paying passenger on a regular scheduled airline?
2 Do you drink wine, beer or spirit? If yes, please state type, quantity and frequency. _________________________________

3 Has any application for or reinstatement of health, life or accident insurance ever been declined, postponed, rated or in any way modified?

4 To the best of your knowledge and belief, has any of your immediate family ever had tuberculosis, diabetes, heart disease, mental disease or any AIDS related
condition?
5 Have you EVER used any habit forming drugs or narcotics or alcohol excessively or treated for alcoholism or drug habits?

6 In the past 12 months,

a) have you smoked cigarettes? If yes, how many per day? _____________
b) did you previously smoke more than you do now? If yes, how many did you smoke when you cut down, stop on whose advice?
c) have you lost more than 3 kgs (6.6 lbs) of weight? If yes, give the reason for the loss.
7 Have you EVER had or been told you had or been treated or are suffering from or taking medicine/ consulting a doctor on:
a) asthma, tuberculosis, respiratory or lung disease?
b) rheumatic fever, high blood pressure, stroke, chest pain, heart murmur, disease of the heart, blood or blood vessels?
c) peptic ulcer or bowel, liver or gall bladder disease?
d) renal stone, abnormal urinalysis or any disorder of the genito-urinary system?
e) epilepsy, mental or nervous disorder?
f) diabetes, venereal disease, cancer, tumour or any other disease, disorder or severe injury?
g) hepatitis or found to be a carrier of hepatitis B?
h) any form of eye, hearing or speech disorder or disease?
i) any disease or disorder of muscles, spine, brain, joints and limbs including loss of sensation, tremor or giddiness?
j) any other disease or injury not mentioned above?
8 Have you been scheduled for any consultation, medical treatment or surgery in the next 12 months?

9 Have you had any surgical operations, investigations, or diagnostic tests (e.g. Ultrasound, Electrocardiogram, Colonoscopy, Barium Meal Exam) OR was otherwise
advised for hospital confinement or surgical that was not performed?
10 Do you engage in hazardous activity or occupation such as flying, scuba / skin diving, motor racing etc.?

11 Do you engage in activities which will increase the likelihood of exposure, or have you received any medical advice, counselling or treatment in connection with AIDS
Related Complex or any other AIDS related condition, or been told you had any of these or that you had a positive HIV blood test or in the last 3 months had any of the
following symptoms for more than 1 week continuously :
fatigue, weight loss, diarrhea, enlarged lymph nodes or unusual skin lesions?
12 In the past 5 years, have you had any :
a) pre-employment/annual check-up, health screening? If yes, please state the result, date done and name and address of clinic where tests are done in the space
provided below.
b) diagnostic tests such as X-ray, electrocardiogram or blood study?
c) double vision, coughing with blood, nose bleeds, tarry stools or bleeding from the rectum or urinary tract?
d) illness, operation, medical advice, hospital treatment not mentioned above?
13 To the best of your knowledge and belief, has any of your family members ever had Down's Syndrome or Familial Polyposis?

14 Female only *
a) Have you ever been to any doctor for a Pap Smear (cervical smear)?
If yes, please state result ___________________________________________________
b) Have you at any time in the past been advised by any doctor to have a repeated Pap Smear within 6 months?
c) Have you ever consulted a doctor for irregular, painful menstruation or other problem(s) involving the female organs, or breasts?
d) Have you been to a doctor for a "breast check-up", or been advised to have an X-ray (mammogram), biopsy, or operation of the breast?
e) Have any of your family members (namely grandmother, aunt(s), mother, sister(s) been diagnosed to have breast cancer? If yes, please complete the following :

Relationship to Employee Age of Diagnosis Breast involvement

One Both Unknown

f) Are you currently pregnant? If so, how many months? ___________

g) Have you ever been pregnant? At what age was your 1st pregnancy?___________

If any of the above answers is "Yes", please give full details in the space provided below
Q. no. Please provide details of diagnosis/condition, result, date of consultation, name and address of clinic and doctor seen

All the foregoing statements and answers in this application form together with those in any required medical examination, questionnaire or amendments are full, complete and true and I
understand that the Company, believing them to be such, will rely and act on them, otherwise any policy issued hereunder may be voided.

Furthermore, I authorise any physician, hospital, clinic or other organisation that has any record or knowledge of me or my health to furnish information concerning my medical history and physical
condition. A photocopy of this authorisation shall be effective and valid as original.

I understand where my application made has caused me to be assured hereunder when I am otherwise ineligible for assured or where such application caused me to remain assured when I would
otherwise be disqualified for further assurance in accordance with the term and limitations of the applied Policy, my assurance shall be voided.

Dated at Singapore this

(ddmmyyyy) Employee's name Employee's signature

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