HEALTH COVER Application Form (Standard Bank Namibia)
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1 FOR OFFICIAL USE OL Policy number HEALTH COVER Application Form (Standard Bank amibia) Important: please read the following before completing this application form Please write clearly using capital and block letters. It is compulsory to complete all the fields in this form. Please submit your completed forms and documents required (see table below) to our in-country office. Existing members who wish to register additional beneficiaries, please complete the Amendment Form available on our website, Each page, other than the signature page, is to be initialled by the Policyholder. DOCUMETS REQUIRED FOR REGISTRATIO WHO THIS APPLIES TO our spouse our living-in partner our adopted child / child placed in custody of the Policyholder or their spouse or living-in partner our or your spouse or living-in partner s biological or natural child (including stepchildren) A child beneficiary student (up to 25 years of age) Special beneficiary (coverage of special beneficiaries is subject to the prior approval of Liberty ) DOCUMET/S REQUIRED AS PROOF Marriage Certificate Proof of Dependency Affidavit stating how long the couple have been living together, which is signed and stamped by a Commissioner of Oaths Copy of the abridged birth certificate Proof of legal adoption Proof of custody Copy of the birth certificate, or hospital confirmation reflecting baby s name (for newborns) A beneficiary who is up to the age of 21 A beneficiary up to the age of 25 provided that the Policyholder submits proof of studies, e.g., written proof of registration for this beneficiary Copy of the birth certificate Proof of Dependency Affidavit, explaining the extent of the financial dependency, and if the special beneficiary is employed, or studying, signed by a Commissioner of Oaths. (e.g. foster child, grandchildren, ex-spouse for whom the Policyholder is liable for medical expenses in terms of the divorce court order). 1. PERSOAL DETAILS PRICIPAL CARD HOLDER Please complete in block capitals Last name First name(s) Title Initials Date of birth Gender (tick where appropriate) M F Identity umber Permanent employment start date Commencement date of cover Plan Option (tick where appropriate) Blue Diamond Blue Diamond Saver Plus (25%) Blue Diamond Saver (15%) Physical address Postal code Postal address (if different to Physical address) Postal code Application Form Standard Bank amibia Version 19 March
2 ame of employer Branch / Department / Division Employee code/ number Occupation Home telephone (please include country and area code) Work telephone (please include country and area code) Mobile (please include country and area code) Salary Code Monthly Income Band $ Tick where appropriate ( ) A B C D E F G BAKIG DETAILS FOR BEEFIT REFUDS Please complete in block capitals Account holder name Account number Account type Savings Cheque Transmission Other Bank Branch name Branch code Signature of account holder Company Stamp Application Form Standard Bank amibia Version 19 March
3 3. REGISTRATIO OF BEEFICIARIES Please complete in block capitals Beneficiary 1 Full ame Please put the full name that will appear on the policyholder card Date of birth Gender M F Relationship to Policyholder Beneficiary 2 Full ame Please put the full name that will appear on the policyholder card M F Beneficiary 3 Full ame Please put the full name that will appear on the policyholder card M F Beneficiary 4 Full ame Please put the full name that will appear on the policyholder card M F Beneficiary 5 Full ame Please put the full name that will appear on the policyholder card M F Please see the descriptions of the type of relationship to the card holder in the first column, first table, page 01 of this document. Application Form Standard Bank amibia Version 19 March
4 4. HEALTH STATEMET Please complete in block capitals. All sections below must be completed - failure to do so will delay processing of this application. ote: If you answer ES to any of the questions in this section, and if the space provided to complete your answer is not sufficient to disclose the necessary information, please provide the additional information on separate pages. First name and last name of current family doctor Telephone How long has he/she been your doctor? year(s) Postal address Have you or any of your nominated beneficiaries received medical advice, care or for any of the following? Postal code 1. Heart & Circulation e.g. Chest pain/angina; Heart attack; Heart failure; Heart valve defects; Rheumatic fever; High blood pressure (Hypertension); High cholesterol; Heart murmurs; Circulatory problems/disorders; Varicose veins; Deep Vein Thrombosis (DVT) or any other heart or circulatory problems. Date of last / ame: 2. Breathing & Respiratory e.g. Asthma; Difficulty with breathing; Bronchospasm; Tuberculosis (TB); Coughing up blood; Emphysema; Pneumonia; Cystic Fibrosis; Chronic bronchitis; Shortness of breath or any other respiratory problems Date of last / ame: 3. Bladder & Kidneys e.g. Blood in urine; Kidney failure; Polycystic kidneys; Kidney or bladder infections; Kidney removal (ephrectomy); Kidney stones; Abnormal kidney or urine tests or any other bladder or kidney problems Date of last / ame: 4. Reproductive Organs e.g. Endometriosis; Infertility; Ovarian Cysts; Hysterectomy; Abnormal pap smears; Cervix or breast biopsies; Fibro-adenosis of the breast; Laparoscopies; Hormone Replacement Therapy (HRT); Prostate infections or surgery; Prostate enlargement or any other reproductive problems Date of last / ame: 5. Digestive System e.g. Duodenal ulcers; Gastric ulcers; Hiatus hernia; Colon problems; Crohn s Disease; Ulcerative colitis; Gall bladder problems; Pancreas; Liver problems or any other digestive system problems Date of last / ame: Application Form Standard Bank amibia Version 19 March
5 6. Ear, ose & Throat e.g. Deafness; Ear infections; Sinus problems; asal surgery; Throat surgery; Orthodontics; Dental surgery; Speech impairments; Harelip; Cleft palate or any other nose or throat problems Date of last / ame: 7. Eyes e.g.blindness (partial or full); Eye surgery; Lens implants; Cataracts; Glaucoma; Retinitis Pigmentosa; Retinal detachment; Impaired vision or any other eye or eyesight problems Date of last / ame: 8. Endocrine e.g. Diabetes ( high blood sugar ); Underactive thyroid; Overactive thyroid; Thyroid surgery; Cushing s Syndrome; Addison s Disease; Pituitary gland problems or any other endocrine or glandular problems Date of last / ame: 9. Back & Muscles e.g. eck or back problems or operations; Recurrent back pain; Osteoporosis; Ankylosing spondylitis; Rheumatoid arthritis; Osteoarthritis; Paget s Disease or any other bone or skeletal disorders Date of last / ame: 10. eurological e.g. Epilepsy; Stroke (CVA); Migraine; Brain injuries; Spinal cord injuries; Paralysis; Cerebral palsy; Multiple Sclerosis; Mental retardation; arcolepsy; Motor euron Disease; Parkinson s Disease; Alzheimer s Disease or any other neurological problems Date of last / ame: 11. Psychological e.g. Depression; Anxiety; Psychosis; Suicide attempts; Bipolar disorders; Manic depression; Stress ; Schizophrenia; Tourette s Syndrome; Anorexia ervosa; Received advice, counselling or for alchohol or drug abuse; Attention Deficit Disorder, Bulimia or any other psychological problems Date of last / ame: Application Form Standard Bank amibia Version 19 March
6 12. Tumours & Growths e.g. Benign or malignant growths or lumps or tumours including but not limited to: Melanoma; Lymph gland cancer; Leukemia and breast cancer or any other tumours, growths and cancers Date of last / ame: 13. Blood Blood or bleeding disorders, e.g., Haemophilia; Christmas factor deficiency; Platelet or any other blood clotting disorders Date of last / ame: 14. Skin e.g. Eczema; Acne; Dermatomyositis; Pemphigus; Psoriasis; Scleroderma or any other skin disorders Date of last / ame: 15. Sexuality e.g. Advice, or counselling for any of the following: HIV/AIDS; Syphilis; Gonorrhoea; Herpes; Genital ulcers; Transmitted Pelvic Infectious Disease (PID); Genital warts; Hepatitis B or any other STI or disorder Infections (STIs) Date of last / ame: Are you or any of your beneficiaries currently pregnant? 16. Pregnancy If the answer to this question is es, when is the expected date of delivery? ame of patient 17. Other medical conditions Do you or any of your nominated beneficiaries have any medical condition not mentioned in the above questions 1 to 16? If yes, please give details of the conditions in the table below. Date of last / ame: Application Form Standard Bank amibia Version 19 March
7 5. DECLARATIO B POLICHOLDER 1. I, the undersigned, hereby apply for myself and my nominated beneficiaries to sign up for. 2. I understand that this application, together with any supporting documents and the Policy Conditions, form the basis of my contract with the Insurer. 3. Declaration in respect of my partner (if applicable): I confirm that my partner and I are in a committed relationship akin to a marriage based on mutual dependency and a shared household. 4. Policy Conditions and benefits a. I agree that I and my beneficiaries will be bound by the Policy Conditions and will abide by them. b. The Insurer shall not be bound in any way by any representations or undertakings made or given by any person save as contained in the Policy Conditions. 5. Exclusions a. I understand that the Insurer may impose exclusions in respect of myself and / or any of my nominated beneficiaries. b. I accept any such exclusion that may be imposed in terms of the Policy Conditions. 6. Banking Details a. I agree to advise the Insurer in writing of any changes to my banking details. b. I understand that failure to do so will result in me being liable for any subsequent banking charges or other costs / losses incurred due to the use of the incorrect banking details. 7. Premiums and amounts owed to the Insurer a. I hereby acknowledge that any credit extended by the Insurer to myself in terms of the Policy Conditions will become payable in full by the end of the benefit year in which it arose and that interest may be charged on all amounts due and owing to the Insurer. b. I acknowledge that it remains my responsibility to ensure that any amounts due by me to the Insurer are paid to the Insurer. c. I agree that any amounts owing by me may be off-set against any benefits or payments that may be due to me by the Insurer. d. I also accept that I will be responsible for any costs associated with the recovery of any debts. 8. Disclosure of information a. I confirm that I have the necessary authorisations to disclose the information that the Insurer may require and provide the necessary authorisations in respect of my nominated beneficiaries. b. I confirm that the information provided in this application, and in any other documents submitted in support of this application, is true, correct and complete and that I have not withheld, concealed or misstated any information. c. I furthermore confirm that I understand that my policy will become null and void should the above statement be found to be incorrect and that in such an event, all monies paid in respect of my policy shall be forfeited and that the Insurer shall furthermore be entitled to recover any amounts paid for services rendered from the provider and/or myself. d. I undertake to promptly advise the Insurer of any change in status of health of myself and any of my nominated beneficiaries that occurs prior to the date of registration with the Insurer and acknowledge that the additional information may be subject to underwriting. I acknowledge that not doing so may lead to the Insurer reconsidering the basis of my policy application. e. I indemnify the trustees, agents and administrator of against any claim, of whatever nature, which may be made against them as a result of or arising out of the disclosure of any medical information in fulfilling this agreement. f. I irrevocably authorise any medical practitioner, hospital, medical institution or other person to disclose information about my own, or my nominated beneficiary s health status to the Insurer or any entity contracted by the Insurer in order to fulfil its functions, duties and obligations in terms of this agreement and I agree that this authorisation shall remain in force after my/their death/s. g. I irrevocably authorise the Insurer to collect, process and share my personal information and that of any nominated beneficiaries with any entity contracted by the Insurer in order to fulfil its functions, duties and obligations in terms of this agreement. I agree that this authorisation shall remain in force after my/ their death/s and understand that this may partially limit my/their right to privacy. 9. Resignation a. I hereby acknowledge that any credit extended by the Insurer to myself in terms of the Policy Conditions will become payable in full upon cancellation of my with the Insurer and that interest may be charged on all amounts due and owing to the Insurer. b. I further acknowledge that on resignation of my, any amounts owing to the Insurer will be deducted from any amounts due to me. c. I confirm that I and all my beneficiaries will cease our current health insurance cover prior to participating in. 10. Personal contact a. I consent to the use of any of the contact details given in this application to send me information pertaining to my (confidential or other). b. I undertake to inform the Insurer of any change of address and contact details. The Insurer shall not be held liable as a result of my neglecting to inform the Insurer of any changes to the aforementioned. c. I consent to my telephone conversations with the Insurer being recorded and forming part of the Insurer s records. I also agree that such records shall remain the sole property of the Insurer. 11. Marketing In order to keep you updated on activities about (LHC), we would like to communicate with you, where necessary, via , SMS or post. a. Do you wish to receive LHC marketing communications? b. If yes, how would you like to receive them? SMS Post c. I consent to LHC marketing products, services and special offers being sent to me from time to time. d. I consent that any Third Party contracted to perform services relating to may contact me from time to time regarding their products, services and special offers. Signed at on this day of 20 Signature of Policyholder Application Form Standard Bank amibia Version 19 March
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