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    Individual Health Proposal Form

    Uploaded by

    waleed majeed
    1) The document is a health insurance application form for State Life Insurance Corporation of Pakistan. It requests information such as the applicant and family member's names, CNIC numbers, occupations, addresses, contact details, and medical histories. 2) The form asks if the applicant or family members have any pre-existing medical conditions, physical deformities, congenital abnormalities, or mental health issues. It also inquires about smoking, alcohol use, and pregnancy. 3) By signing the form, the applicant agrees to provide true and complete information and understands that withholding relevant details could result in a denied claim or cancelled policy.

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    © All Rights Reserved
    Download as PDF, TXT or read online from Scribd

    Individual Health Proposal Form

    Uploaded by

    waleed majeed
    18 views1 page
    1) The document is a health insurance application form for State Life Insurance Corporation of Pakistan. It requests information such as the applicant and family member's names, CNIC numbers, occupations, addresses, contact details, and medical histories. 2) The form asks if the applicant or family members have any pre-existing medical conditions, physical deformities, congenital abnormalities, or mental health issues. It also inquires about smoking, alcohol use, and pregnancy. 3) By signing the form, the applicant agrees to provide true and complete information and understands that withholding relevant details could result in a denied claim or cancelled policy.

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    © © All Rights Reserved

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    1) The document is a health insurance application form for State Life Insurance Corporation of Pakistan. It requests information such as the applicant and family member's names, CNIC numbers, occupations, addresses, contact details, and medical histories. 2) The form asks if the applicant or family members have any pre-existing medical conditions, physical deformities, congenital abnormalities, or mental health issues. It also inquires about smoking, alcohol use, and pregnancy. 3) By signing the form, the applicant agrees to provide true and complete information and understands that withholding relevant details could result in a denied claim or cancelled policy.

    Copyright:

    © All Rights Reserved
    Download as PDF, TXT or read online from Scribd
    Download as pdf or txt
    18 views1 page

    Individual Health Proposal Form

    Uploaded by

    waleed majeed
    1) The document is a health insurance application form for State Life Insurance Corporation of Pakistan. It requests information such as the applicant and family member's names, CNIC numbers, occupations, addresses, contact details, and medical histories. 2) The form asks if the applicant or family members have any pre-existing medical conditions, physical deformities, congenital abnormalities, or mental health issues. It also inquires about smoking, alcohol use, and pregnancy. 3) By signing the form, the applicant agrees to provide true and complete information and understands that withholding relevant details could result in a denied claim or cancelled policy.

    Copyright:

    © All Rights Reserved
    Download as PDF, TXT or read online from Scribd
    Download as pdf or txt
    of 1

    STATE LIFE

    INSURANCE CORPORATION OF PAKISTAN HEALTH INSURANCE APPLICATION FORM

    Policy Number: (to be filled by State Life) Proposal Date:


    Name of Applicant (in block letters) *:

    (S/O, D/O, W/O, H/O) *:


    Applicant CNIC No*.:

    Occupation:

    Postal Address*: City*:

    Contact No.*: Alternate Contact No.:

    Email Address:

    FAMILY MEMBERS TO BE COVERED (please use additional sheets, if necessary).


    S. NO NAME CNIC NO. RELATIONSHIP DATE OF BIRTH* GENDER*
    1* *As Above* *As Above* SELF
    2
    3
    4
    5
    6

    (Please read the following questions carefully and answer each question by ticking the appropriate box)
    1) Have you or any of your family members (Spouse/Children/Parents):
    a. Suffering from any medical condition/disease/illness/injury? If yes, details Yes No
    b. Receiving any diagnosis from a Doctor/Hakeem or Homeopath (even if no treatment is provided)? Yes No
    c. Are any of the members listed above suffering/suffered from any physical deformity? Yes No
    d. Do any of the members listed above have/had any congenital abnormality/birth defect? Yes No
    e. Do any of the members listed above suffer or have suffered from any mental, psychiatric or nervous disorders?
    Yes No
    2) Do you or any member of your family smoke or consume alcohol? Yes No
    3) Are you or your spouse pregnant? If yes, how many months? Yes No
    4) Are you and all members of your family (listed above) in good health? Yes No
    PLEASE PROVIDE DETAIL(S) FOR THE QUESTION(S) 1(a) to 1(e) TICKED” YES”.
    PRESENT STATUS
    NAME OF THE PERSON WITH PRE-EXISTING NAME OF THE HOSPITAL/ATTENDING
    NATURE OF ILLNESS ON MEDICINE/SURGERY
    CONDITION PHYSICIAN
    AWAITED/RECOVERED)

    Plan Name: ______________________________ Plan Category/Coverage: ________________________ Premium Amount (Office Use): _________________
    FOLLOWING DOCUMENTS MUST BE ATTACHED WITH THE FORM
    [ ] CNIC / B-Form Of Members [ ] Declaration Form (For Specific Products)

    DECLARATION
    I, on behalf of any included dependents and myself apply for health insurance cover and agree to be bound by the policy document. I declare that, to the b est of my knowledge and belief the answers and information I
    have given are true, accurate and complete and that I have not withheld any information in regard to this application that ought to be disclosed to State Life Insurance Corporation of Pakistan. I understand that if any of
    the information provided by me is incorrect or incomplete, State Life Insurance Corporation of Pakistan will be entitled to refuse to pay my benefits and/or cancel my policy.
    ‫ت‬ ‫ت‬ ‫ت‬ ‫ت‬ ‫ت‬
    ‫ریمےملعےکاطمقبںیمےنوجلعمامتاوروکائفرامہےیکںیہوہدرساورلمکم ںیہ۔اسدروخاسےک ےلسلسںیمایسیوکیئ‬،‫رکپوہں ہک‬ ‫افکلافرادیک ب‬
    ‫اجن ےس ھتلیہاوشنرسنےکوصحلےکےیلدروخاسداتیوہںاورپایسیلداتسویریکرشاطئ اکپادنبروہاگن۔ ںیمدصتی ا‬ ‫ںیم اےنپاورزیر‬
    ‫پاریمیپایسیل وسنمخرک ےناکدقحاروہاگ۔‬/‫وتاٹیٹسالئاوشنرسناکروپرنشیآفپااتسکنریمے وفادئیکادایگیئ ےسااکنررکےناور‬،‫لعمامت ہیفخ ںیہنریھکیئگںیہوجہکاٹیٹسالئاوشنرسناکروپرنشیآفپااتسکنوکاظہررکپا رضوریوہں۔ارگفرامہرکدہلعمامتطلغپاپالمکم وہں‬

    ____________________________
    Signature of Applicant

    FOR OFFICE USE ONLY


    Name of Zone: _______________________________-
    (Marketing Agent Information)

    Code: Full Name:


    CNIC:_______________________ Contact No :

    Email: [email protected] or Toll Free: 0800-07007

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