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Addition Form

The document is an application form for adding dependents to an existing member's group Medicare plan with Amanah Insurance. It includes instructions for completion, personal information requirements, and a section for medical history of the dependents. The form must be signed by the principal member and stamped by the HR/Admin Manager to be accepted.

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xanbali
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9 views

Addition Form

The document is an application form for adding dependents to an existing member's group Medicare plan with Amanah Insurance. It includes instructions for completion, personal information requirements, and a section for medical history of the dependents. The form must be signed by the principal member and stamped by the HR/Admin Manager to be accepted.

Uploaded by

xanbali
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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AMANAH INSURANCE

GROUP MEDICARE AMANAH


DEPENDANT ADDITION FORM
APPLICATION INSTRUCTIONS:
1. This Form use only Dependents ADDITION of the Existing Member with Amanah Insurance
2. To be completed by Employee (On behalf of his Dependents).
3. Please answer all Questions clearly in BLOCK/CAPITAL Letters.
4. Kindly complete all questions in full. Incomplete applications form cannot be processed.
5. Application Form must be signed and stamped by your HR/Admin Manager where indicated (Page
3). Without sign and stamped by HR/Admin Manager applications forms cannot be accepted.
6. Be sure your (Principal Member) Sign and Date. Without your sign applications form cannot be
accepted.
7. Attached Photo where indicated (Page 3) and write the appropriate Name and DOB under the Photo.
1. PRINCIPAL MEMBER INFORMATION
Full Name of Principal Member
Membership No (Mandatory)
Policy No

2. CHANGE INFORMATION
Reason for ADDING Dependents (Please Select)
Marriage
Birth
Others (Pls. Explain) With Effect From D D M M Y Y Y

3. DETAILS OF DEPENDANT(S)
[Please note children will be eligible for cover from the age of 61 Days up to 21 years (Unmarried Only). Children above 21
years but below 25 years may be accepted on proof of fulltime schooling.]
No Full Name Date of Birth Gender Relation
1 D D M M Y Y Y Y M F
2 D D M M Y Y Y Y M F
3 D D M M Y Y Y Y M F
4 D D M M Y Y Y Y M F
5 D D M M Y Y Y Y M F
6 D D M M Y Y Y Y M F
7 D D M M Y Y Y Y M F
8 D D M M Y Y Y Y M F
9 D D M M Y Y Y Y M F
10 D D M M Y Y Y Y M F
Please Provide Additional Information while ADDING Spouse:
Full Name
Nationality ID/Passport No
Mobile Phone Email ID

Page 1 of 3
AMANAH INSURANCE
4. CONFIDENAMANAHL MEDICAL HISTORY
State whether any of your dependants have ever been treated or are currently receiving treatment, or expect to
receive treatment for any of the following illnesses including but not limited to:
Please indicate YES or NO in the box below
Question Spouse Dependents
1 Blood disorders. e.g. anemia, bleeding disorders, leukemia

2 Cancer, growths or tumors whether benign or malignant


Cardiovascular (heart and blood vessels) disorders e.g. high blood
3
pressure, varicose veins, palpitations, deep vein thrombosis
4 Endocrine disorders e.g. diabetes, high cholesterol , thyroid abnormalities

5 Genito-urinary system, Gynecological and Obstetrical disorders

6 Neurological disorders e.g. epilepsy, Stroke

7 Psychological disorders e.g. alcohol or drug dependency, anxiety disorder


Respiratory disorders e.g. asthma, rhinitis, chronic bronchitis, cigarette
8
smoking related disorders, tuberculosis, pulmonary disease,
Skin disorders e.g. eczema, melanoma, skin cancer, burns, scars, keloids,
9
warts
Have you or any of your dependants ever treatment in connection with
10
HIV or AIDS infections or tested positive for HIV or AIDS?
Do you or any of your dependants have any hereditary disorders, birth
11
defects or congenital conditions?
Are you or any of your dependants on any medication (please indicate in
12
the table provided below)
If you answered YES (No. 12) please write details below:
Prescribed Date Started/To
Name of Person Diagnosis
Medication Be Started

If you answered YES to any of the questions (No. 01-11) above, please write details below:
Q. Consulting
Name of Person Date Diagnosis Treatment
NO. Doctor

(If the space provided is insufficient, please attach additional information to this application.)
N.B: Any misrepresentation or non-disclosure of material or factual information will render all benefits granted by
Amanah Insurance null and void. In addition, any claims payment made due to such actions will be recoverable
from the policy holder.

Page 2 of 3
AMANAH INSURANCE

4. DECLARATION
I, the undersigned principal applicant member Warrant that the contents of this application and any other documents which
may be required in support thereof are true, correct and complete to the best of my knowledge and belief. This addition form
is the part of my application form which I submitted earlier.

______/______/________ ________________________________
Date Signature of Principal Member
THIS SECTION FILLED UP BY THE EMPLOYER/ORGANIZATION
Stamp of Employer (Mandatory) Signature of Authorized Person of Employer

_____________________________________________

Date: Full Name:

___/____/______ _________________________________________

(If the space provided is insufficient, please attach additional page to this application.)
Page 3 of 3

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