Individual Membership Application Form
Personal Details
Company
Name
First Name
Last Name
Email
example@example.com
Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Phone Number
Please enter a valid phone number.
Date of Birth
-
Month
-
Day
Year
Date
Sex
Male
Female
Marital Status
Single
Married
Divorced
Widowed
ID Number
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Medical History
(To be completed by all applicants) (Pre-existing conditions are excluded from foreign travel emergency)Please read carefully and complete all the required information by placing a tick in the correct box. If the answer to any of the questions is YES, please provide details in the space provided below in respect of the member or dependents applicable. Failure to disclose material information or the provision of incorrect information can result in immediate cancellation of your membership of benefits.
Are you experiencing or have experienced any of the following?
1. Heart(cardiac) Diseases:heart attack, rheumaticfever, congenital heart abnormalities, angina, embolism, high blood pressure
2. Circulatory:varicose veins/thrombosis,blooddisorders(e.g.,anaemia,leukemia)
3. Diseases of the Liver: jaundice, gall bladder diseases, liver cirrhosis
4. Disease of the Airway/ Lungs: Asthma, chronic bronchitis, tuberculosis, emphysema, cystic fibrosis, interstitial fibros of any cause
5. Disease of the digestivesystem: gastric/ duodenal ulcers, hiatus hernia, severe recurring diarrhoea
6. Diseaseofthebladder/kidney:kidney stone,congenitalkidneydisorder,nephritis,bladderinfections
7. Neurological conditions: Migraine, stroke, epilepsy
8. Diseases of the bone: joints and muscles, rheumatic arthritis, gout, back. neck. joint problems
9. Endocrine conditions: diabetes mellitus, thyroid disease (e.g.; goitre)
10. Mental Health conditions: Psychotic conditions (e.g, schizophrenia) mood disorder, anxiety disorder (e.g., panic disorders)
Other
If you ticked Other kindly explain the condition below
Are you currently taking medication for any permanent or recurring condition?
Yes
No
If so please detail name, dosage & frequency.
If you have ticked YES for any of the above, please complete the section below. Please note all important information must be disclosed. The following section is for details of 1-14
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Dependents
Name
First Name
Last Name
ID Number
Date of Birth
-
Month
-
Day
Year
Date
Are you experiencing or have experienced any of the following?
1. Heart(cardiac) Diseases:heart attack, rheumaticfever, congenital heart abnormalities, angina, embolism, high blood pressure
2. Circulatory:varicose veins/thrombosis,blooddisorders(e.g.,anaemia,leukemia)
3. Diseases of the Liver: jaundice, gall bladder diseases, liver cirrhosis
4. Disease of the Airway/ Lungs: Asthma, chronic bronchitis, tuberculosis, emphysema, cystic fibrosis, interstitial fibros of any cause
5. Disease of the digestivesystem: gastric/ duodenal ulcers, hiatus hernia, severe recurring diarrhoea
6. Diseaseofthebladder/kidney:kidney stone,congenitalkidneydisorder,nephritis,bladderinfections
7. Neurological conditions: Migraine, stroke, epilepsy
8. Diseases of the bone: joints and muscles, rheumatic arthritis, gout, back. neck. joint problems
9. Endocrine conditions: diabetes mellitus, thyroid disease (e.g.; goitre)
10. Mental Health conditions: Psychotic conditions (e.g, schizophrenia) mood disorder, anxiety disorder (e.g., panic disorders)
Other
Name
First Name
Last Name
ID Number
Date of Birth
-
Month
-
Day
Year
Date
Are you experiencing or have experienced any of the following?
1. Heart(cardiac) Diseases:heart attack, rheumaticfever, congenital heart abnormalities, angina, embolism, high blood pressure
2. Circulatory:varicose veins/thrombosis,blooddisorders(e.g.,anaemia,leukemia)
3. Diseases of the Liver: jaundice, gall bladder diseases, liver cirrhosis
4. Disease of the Airway/ Lungs: Asthma, chronic bronchitis, tuberculosis, emphysema, cystic fibrosis, interstitial fibros of any cause
5. Disease of the digestivesystem: gastric/ duodenal ulcers, hiatus hernia, severe recurring diarrhoea
6. Diseaseofthebladder/kidney:kidney stone,congenitalkidneydisorder,nephritis,bladderinfections
7. Neurological conditions: Migraine, stroke, epilepsy
8. Diseases of the bone: joints and muscles, rheumatic arthritis, gout, back. neck. joint problems
9. Endocrine conditions: diabetes mellitus, thyroid disease (e.g.; goitre)
10. Mental Health conditions: Psychotic conditions (e.g, schizophrenia) mood disorder, anxiety disorder (e.g., panic disorders)
Other
Name
First Name
Last Name
ID Number
Date of Birth
-
Month
-
Day
Year
Date
Are you experiencing or have experienced any of the following?
1. Heart(cardiac) Diseases:heart attack, rheumaticfever, congenital heart abnormalities, angina, embolism, high blood pressure
2. Circulatory:varicose veins/thrombosis,blooddisorders(e.g.,anaemia,leukemia)
3. Diseases of the Liver: jaundice, gall bladder diseases, liver cirrhosis
4. Disease of the Airway/ Lungs: Asthma, chronic bronchitis, tuberculosis, emphysema, cystic fibrosis, interstitial fibros of any cause
5. Disease of the digestivesystem: gastric/ duodenal ulcers, hiatus hernia, severe recurring diarrhoea
6. Diseaseofthebladder/kidney:kidney stone,congenitalkidneydisorder,nephritis,bladderinfections
7. Neurological conditions: Migraine, stroke, epilepsy
8. Diseases of the bone: joints and muscles, rheumatic arthritis, gout, back. neck. joint problems
9. Endocrine conditions: diabetes mellitus, thyroid disease (e.g.; goitre)
10. Mental Health conditions: Psychotic conditions (e.g, schizophrenia) mood disorder, anxiety disorder (e.g., panic disorders)
Other
Name
First Name
Last Name
ID Number
Date of Birth
-
Month
-
Day
Year
Date
Are you experiencing or have experienced any of the following?
1. Heart(cardiac) Diseases:heart attack, rheumaticfever, congenital heart abnormalities, angina, embolism, high blood pressure
2. Circulatory:varicose veins/thrombosis,blooddisorders(e.g.,anaemia,leukemia)
3. Diseases of the Liver: jaundice, gall bladder diseases, liver cirrhosis
4. Disease of the Airway/ Lungs: Asthma, chronic bronchitis, tuberculosis, emphysema, cystic fibrosis, interstitial fibros of any cause
5. Disease of the digestivesystem: gastric/ duodenal ulcers, hiatus hernia, severe recurring diarrhoea
6. Diseaseofthebladder/kidney:kidney stone,congenitalkidneydisorder,nephritis,bladderinfections
7. Neurological conditions: Migraine, stroke, epilepsy
8. Diseases of the bone: joints and muscles, rheumatic arthritis, gout, back. neck. joint problems
9. Endocrine conditions: diabetes mellitus, thyroid disease (e.g.; goitre)
10. Mental Health conditions: Psychotic conditions (e.g, schizophrenia) mood disorder, anxiety disorder (e.g., panic disorders)
Other
Name
First Name
Last Name
ID Number
Date of birth
-
Month
-
Day
Year
Date
Are you experiencing or have experienced any of the following?
1. Heart(cardiac) Diseases:heart attack, rheumaticfever, congenital heart abnormalities, angina, embolism, high blood pressure
2. Circulatory:varicose veins/thrombosis,blooddisorders(e.g.,anaemia,leukemia)
3. Diseases of the Liver: jaundice, gall bladder diseases, liver cirrhosis
4. Disease of the Airway/ Lungs: Asthma, chronic bronchitis, tuberculosis, emphysema, cystic fibrosis, interstitial fibros of any cause
5. Disease of the digestivesystem: gastric/ duodenal ulcers, hiatus hernia, severe recurring diarrhoea
6. Diseaseofthebladder/kidney:kidney stone,congenitalkidneydisorder,nephritis,bladderinfections
7. Neurological conditions: Migraine, stroke, epilepsy
8. Diseases of the bone: joints and muscles, rheumatic arthritis, gout, back. neck. joint problems
9. Endocrine conditions: diabetes mellitus, thyroid disease (e.g.; goitre)
10. Mental Health conditions: Psychotic conditions (e.g, schizophrenia) mood disorder, anxiety disorder (e.g., panic disorders)
Other
Name
First Name
Last Name
ID Number
Date of Birth
-
Month
-
Day
Year
Date
Are you experiencing or have experienced any of the following?
1. Heart(cardiac) Diseases:heart attack, rheumaticfever, congenital heart abnormalities, angina, embolism, high blood pressure
2. Circulatory:varicose veins/thrombosis,blooddisorders(e.g.,anaemia,leukemia)
3. Diseases of the Liver: jaundice, gall bladder diseases, liver cirrhosis
4. Disease of the Airway/ Lungs: Asthma, chronic bronchitis, tuberculosis, emphysema, cystic fibrosis, interstitial fibros of any cause
5. Disease of the digestivesystem: gastric/ duodenal ulcers, hiatus hernia, severe recurring diarrhoea
6. Diseaseofthebladder/kidney:kidney stone,congenitalkidneydisorder,nephritis,bladderinfections
7. Neurological conditions: Migraine, stroke, epilepsy
8. Diseases of the bone: joints and muscles, rheumatic arthritis, gout, back. neck. joint problems
9. Endocrine conditions: diabetes mellitus, thyroid disease (e.g.; goitre)
10. Mental Health conditions: Psychotic conditions (e.g, schizophrenia) mood disorder, anxiety disorder (e.g., panic disorders)
Other
Name
First Name
Last Name
ID Number
Date of Birth
-
Month
-
Day
Year
Date
Submit
Are you experiencing or have experienced any of the following?
1. Heart(cardiac) Diseases:heart attack, rheumaticfever, congenital heart abnormalities, angina, embolism, high blood pressure
2. Circulatory:varicose veins/thrombosis,blooddisorders(e.g.,anaemia,leukemia)
3. Diseases of the Liver: jaundice, gall bladder diseases, liver cirrhosis
4. Disease of the Airway/ Lungs: Asthma, chronic bronchitis, tuberculosis, emphysema, cystic fibrosis, interstitial fibros of any cause
5. Disease of the digestivesystem: gastric/ duodenal ulcers, hiatus hernia, severe recurring diarrhoea
6. Diseaseofthebladder/kidney:kidney stone,congenitalkidneydisorder,nephritis,bladderinfections
7. Neurological conditions: Migraine, stroke, epilepsy
8. Diseases of the bone: joints and muscles, rheumatic arthritis, gout, back. neck. joint problems
9. Endocrine conditions: diabetes mellitus, thyroid disease (e.g.; goitre)
10. Mental Health conditions: Psychotic conditions (e.g, schizophrenia) mood disorder, anxiety disorder (e.g., panic disorders)
Other
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