Sagicor Application Form

Member Enrolment Form

For Employer Use

Type a question

Rows	Name Member/ Company	Policy Number	Account Number
-

Location
Date Hired

MonthDayYear
Date
Effective Date

MonthDayYear
Date
Salary
Salary In Numbers
Remarks

EMPLOYEE INFO

**All fields in the Employee Info Section must be completed before processing can take place**
EMPLOYEE TRN
D.O.B

DayMonthYear
Date
Name

First NameMiddle NameLast Name
Occupation

Rows	Marital Status	Sex
-

BANK INFORMATION

Rows	BNS	FCIBC	NCB	CITI	FGB	SBJ
Bank Info

Account Type

ChequingSaving
Rows Account # Branch

-

Rows	Account #	Branch
-

CONTACT INFORMATION
Address

Street Address

Street Address Line 2
Telephone
Please enter a valid phone number.
Cell Phone
Please enter a valid phone number.
Email
example@example.com

Rows	Life	AD&D	DISABILITY INC.
YES
NO

DEPENDENT 1

First NameMiddle InitialLast Name
D.O.B

DayMonthYear
Date
SEX

MF
TRN
RELATION (S/C)
DEPENDENT 2

First NameMiddle NameLast Name
D.O.B

DayMonthYear
Date
SEX

MF
TRN
RELATION (S/C)
DEPENDENT 3

First NameMiddle NameLast Name
D.O.B

DayMonthYear
Date
SEX

MF
TRN
RELATION (S/C)

BENEFICIARIES

All Beneficiaries listed below are deemed to be revocable beneficiaries unless otherwise stated. If the beneficiary elected is less than 16 years of age, an adult must be appointed as a Trustee.

BENEFICIARIES

Rows	Name	Relationship	% Allocation	Trustee Name
-
-
-

As provided under my Employer’s Group Contract with Sagicor Life Jamaica Limited, I elec t coverage as indicated above on beha lof f myself and my eligible dependent(s) as listed above (where applicable) and authorize my
employer to deduct from my earnings the contributions required (if any) for the benefits elected.

Having elected a Medical (including HMO), Dental and/or Optical Plan, I authorize Sagicor Life Jamaica Limited to have access to, and copies of, all medical, Hospital or other institution/agency records relating to the diagnosis,
treatment or services providedt o me or a covered dependent.

I hereby instruct my employer that, in the event of my death, all proceeds, payments or benefits which become due be paid to the person(s) named above under, “BENEFICIARY”, and reserve for myself the sole right to change my
instructions by informing my employer in writing.

I certify that the above information is correct to the best of my knowledge and confirm that I understand the conditions as stated above.

* I understand that the Effective Date of this insurance is subject to (a) my being actively at work on the day in question; (b) the rules and conditions of the company’s underwriters as laid out in the Group Insurance Contract.
Signature of Employee

Powered by Jotform SignClear
Date

DayMonthYear
Date
[If employee is applying for coverage outside of eligibility period, please complete Health Statement on reverse]

GROUP INSURANCE STATEMENT OF HEALTH

TO BE COMPLETED BY THE EMPLOYEE

Rows	Employer	Employee	Group Policy No.	Employee's D.O.B
-

Rows	Occupation	Date Employed	Height	Weight
-

Rows	Eligible Dependents (Spouse/Children)	Relationship to Employee	Height	Weight	Date of Birth
-
-
-

Rows	Employee	Spouse	Children
YES
NO

Rows	Employee	Spouse	Children
YES
NO

Rows	Employee	Spouse	Children
YES
NO

Rows	Employee	Spouse	Children
YES
NO

Rows	Employee	Spouse	Children
YES
NO

Rows	Employee	Spouse	Children
YES
NO

Rows	Employee	Spouse	Children
YES
NO

Rows	Employee	Spouse	Children
YES
NO

Rows	Employee	Spouse	Children
YES
NO

Rows	Employee	Spouse	Children
YES
NO

Rows	Employee	Spouse	Children
YES
NO

Rows	Employee	Spouse	Children
YES
NO

Rows	Employee	Spouse	Children
YES
NO

Rows	Employee	Spouse	Children
YES
NO

Rows	Employee	Spouse	Children
YES
NO

Rows	Employee	Spouse	Children
YES
NO

Rows	Employee	Spouse	Children
YES
NO

Rows	Employee	Spouse	Children
YES
NO

Rows	Employee	Spouse	Children
YES
NO

Rows	Employee	Spouse	Children
YES
NO

Rows	Employee	Spouse	Children
YES
NO

Rows	Employee	Spouse	Children
YES
NO

PART B – TO BE COMPLETED BY EMPLOYER

1. Is the employee now at work and able to perform full duties?

Rows	Yes	No	If ‘No’, give details
-

2. Is the employee employed full-time, working more than 30hours every week?

Rows	Yes	No	If ‘No’, give details
-

3. Has the employee been absent from work due to sickness or injury during the past 6 months?

Rows	Yes	No	If ‘Yes’, give details
-

4. Do you know of any prior or existing serious physical impairment, history of drug abuse or alcoholism?

Rows	Yes	No	If ‘Yes’, give details
-

Date

DayMonthYear
Date
Signature for Employer

Powered by Jotform SignClear
Title
Should be Empty:

Rows	MED	HMO	DENTAL	OPTICAL
EE ONLY
DEP (S)

Rows	Quest. No	Full Name of Person Treated	Nature of Ailment	Date(s) of Visit(s)	Degree of Recovery (F- Full; P = Partial; C = Continuing	Complete Name & Address of Attending Physician/Dentist
-
-
-
-

Member Enrolment Form

EMPLOYEE INFO

BANK INFORMATION

CONTACT INFORMATION

BENEFICIARIES

GROUP INSURANCE STATEMENT OF HEALTH

During the past five (5) years, have you or any of your dependents:

Authorization to Obtain and Release Information:

PART B – TO BE COMPLETED BY EMPLOYER