ICC Health Care Application Form

ICC Health Care Application Form

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ICC PA Application Form

ICC Health Care

APPLICATION FORM

Please provide the following contact information:

First Name

Last Name

Street Address

Address (cont.)

City

Zip/Postal Code

Work Phone

Home Phone

FAX

E-mail

Plan Selected:

Policy Commencing Date: -- mm/dd/yy

Option IPD IPD+OPD

Details of person to be covered (1)

First Name

Last Name

Date of Birth

Sex Male Female

Height

Weight

ID Number

Subscription Amount (1)

Details of persons to be covered (2)

First Name

Last Name

Date of Birth

Sex Male Female

Height

Weight

ID Number

Subscription Amount (2)

Details of person to be covered (3)

First Name

Last Name

Date of Birth

Sex Male Female

Height

Weight

ID Number

Subscription Amount (3)

Details of persons to be covered (4)

First Name

Last Name

Date of Birth

Sex Male Female

Height

Weight

ID Number

Subscription Amount(4)

Health and other Declarations

1. Does the applicant or any of the persons covered have health or accident insurance with other insurance companies?

No
Yes, please give details

2. Has the applicant or person covered ever had a request for life insurance rejected by another insurance company?

No
Yes, please give details

3. Have you ever undergone an operation?

Application No Yes, please give details

Spouse No Yes, please give details

Children No Yes, please give details

4. Have you ever been recommended surgery?

Application No Yes, please give details

Spouse No Yes, please give details

Children No Yes, please give details

5. Have you ever been hospital?

Application No Yes, please give details

Spouse No Yes, please give details

Children No Yes, please give details

Select any of the following options that apply: if any of the persons covered have suffered from the following illnesses, injuries, physical impairment/ deformity or condition requiring in-patient treatment, operation or consultation with a medical practitioner.
Psychiatric illness or Nervous Disorder	Eye Disorder
Ear, Nose and Throat Disorder	Lung Disorder
Stomach Disorder	Intestines or Bowel Disorder
Liver Disease	Kidney or Bladder Disease
Prostate Disease	Disease of the Sexual Organs
Thyroid Disease	Allergies
Heart Disease	High or Low Blood Pressure
Hypercholesterol	Disorder of the Joints or Muscles, Gout
Bone Disorder	Skin Disease
Cancer	Non Malignant Growth
Bodily Deformity (From birth or accident)	Diabetes
Breast Disease	Disease of the uterus, ovaries or tubes
Menstrual Disorders	Other (Please specify)

Name of Beneficiary for Personal Accident Claim:

Relationship:

Please state the name of the physical, hospital or clinic together with address which the applicant or person covered use regularly:

All the above statements are true and complete to the best of my knowledge and belief and I understand that the Company, believing them to be such, will rely and act on them. Furthermore, I authorise any physician or hospital or any organisation that has any records or knowledge of me or my health to furnish Independent Consultant Co., Ltd. with information concerning my medical history and physical condition. A photocopy of this authorisation shall be as effective and valid as the original.

The application must truthfully answer all questions. Any concealment or misrepresentation of the truth may result in the insurance company refusing to honour insurance claims, as per clause 865 of Civil and commercial Code. If you have any queries regarding this Insurance Policy, please contact the Office of the Insurance Commissioner, Telephone 619-0382, 619-0613-9

To send this form by fax, print this form and fill in the form, thank you.
Proposer's Signature	...................................................................
Date	...................................................................