Insurance Form
Insurance Form
Insurance Form
7. Do you have life accident, disability or hospital insurance now or being applied for? If "yes", what companies, amount
and type of coverage, YES( ) NO( )
8. Have you ever had any application for life accident, sickness, disability or hospital Insurance declined, postpone,
modified, rated up, cancelled or renewal refused? If "yes" state kind of insurance, company, date and reason. YES ( )
NO( )
9. Is the weekly Indemnity under all policies you have and are applying for less than 75% of your average weekly earnings?
YES( ) NO( )
10. Do you contemplate any journey outside Philippines, or any hazardous undertaking? If "yes" give details.
YES( ) NO( )
11. To the best of your knowledge and belief:
a) Have you ever had abnormal blood pressure, ulcer, tuberculosis, hernia, diabetis, cancer, syphilis, paralysis,
arthritis, rheumatism, any disorder or disease of the mental nervous, genito urinary or digestive system, back spine or
heart? YES( ) NO( )
b) Have you ever been under medical observation, had medical advice or treatment or been hospitalized during the
past five years? YES( ) NO( ) If "a" or "b" answer "yes", give complete details
Nature Nature of Disability Doctor/Hospital Result
12. Do you have any physical deformity, impairment of hearing or vision, or loss of hand, foot or vision? If "yes"
give details. YES( ) NO( )
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Applicant Signature