Heath, Insurance and Emergency Contact

Form
I, First Name* Last Name* , hereby give permission to my Agent, Danel Vermaak to obtain and hold this form with my personal information in the event of an emergency.

I agree that the information herein may be shared with the appropriate parties should I be unable to provide the information myself. The parties include but are not limited to, The American Agent, Employing Farmer,
Doctor, Hospital, Coroner, Workers Comp, DOL etc..

I agree that the information given in this form is true and accurate to the fullest extent of my knowledge.

I agree that I fully understand the use of this form and the language it is provided in.

I agree and understand that i can choose not to provide information I am not comfortable with (Emergency Contact excluded)
Signature*

Powered by Jotform SignClear
Date*

DayMonthYear
Date

Name*

First NameMiddle NameLast Name
Date of Birth*

MonthDayYear
Date
SA ID number*
Passport Number*
Visa Number*

INSURANCE INFORMATION

You are not obligated to provide this information
Did you purchase Travel Insurance for the duration of your stay in the United States?*

YesNoPrefer not to say
Configurable list*
Are you covered by any other insurance while in the US (Besides Workers Comp)*

YesNo
Please Explain*

Do you take any prescription Medication?*

YesNoPrefer not to say
Please List Medication
Do you have any Allergies*

YesNoPrefer not to say
Please List Allergies (with reaction)

EMERGENCY CONTACTS

MUST PROVIDE AT LEAST 1
Emergency Contact 2

I, First Name Last Name , agree that I have willfully provided all of the above information.
Signature

Powered by Jotform SignClear
Should be Empty: