| |
|
| Plan
Type |
 Excluding US Coverage Including US
Coverage
|
| Proposed Insured |
First
_____________________ Middle _____________________ Last
_____________________ |
| Non-US Address |
_____________________________________________________________________________ |
| |
_________________________________________ Daytime Phone Number
________________ |
| US
Address |
_____________________________________________________________________________ |
| |
_________________________________________ Daytime Phone Number
________________ |
| Personal Info. |
Date
of Birth _____________________ Height __________ Weight __________ Sex
_________ |
| Citizen
of what country |
_____________________________________________________________________________ |
| Occupation |
_____________________ Details of Duties
__________________________________________ |
| Medical Attendant |
_____________________________________________________________________________ |
| Address |
_____________________________________________________________________________ |
| Time outside US |
(per
year, please) ___________________ Deductible Requested
_________________________ |
| Effective Date |
________________________ (Earliest effective date is 24 hours
after Underwriting approval.) |
| Optional Benefit |
Hazardous
Sports: Specify Sport _______________________ |
| |
|
Questions 1-22 must be answered to receive a consideration for
coverage. For ALL questions that you answer "YES," please provide details
of the medical condition including treatment, dates, name, address and
phone number of attending physician, diagnosis, prognosis, and present
course of treatment on a separate sheet. Please attach these responses
to this application. The Underwriters may request additional medical
information. |
|
|
1) During the past 5 years, have you been diagnosed with
any medical condition, received treatment (including medications and
consultations), or been hospitalized for any medical, mental, or nervous
conditions? |
|
|
2) Are you currently disabled or unable to perform normal
activities? |
|
|
3) Have you ever been declined or accepted on a modified basis for
life, disability or medical insurance? |
|
|
4) Have you ever received treatment or joined an
organization for alcoholism or drug dependency? |
|
|
5) Have you been diagnosed or treated for Acquired Immune
Deficiency Syndrome (AIDS), AIDS related complex (ARC), Lymphadenopathy
Syndrome, or any Immune System Disorder? |
|
|
|
|
Have you EVER been treated for, or have been told that, or
have reason to believe that you have any diseases, conditions, medical
problems, disorders, sicknesses or problems relating to any of the
following: |
|
|
6) Heart? |
|
|
7) Blood Vessels or circulatory system? |
|
|
8) Blood Pressure? |
|
|
9) Diabetes or glands? |
|
|
10) Cancer, tumor, cyst or growth? |
|
|
11) Stomach, bowel or intestines? |
|
|
12) Kidney, liver or gall bladder? |
|
|
13) Lung or respiratory system? |
|
|
14) Sight or Hearing? |
|
|
15) Mental or nervous system? |
|
|
16) Bone, skeleton, muscles, joints or skin? |
|
|
17) Allergy? |
|
|
18) Epilepsy? |
|
|
19) Genito-urinary system? |
|
|
20) Reproductive system? |
|
|
21) Have you ever been treated for or had any indication
of physical disorder, injury or abnormality, not disclosed elsewhere on
this application? |
|
|
22) Have you ever applied to Lloyd's for Medical Coverage
in the past? |
| |
|
|
Please remember to attach a separate
sheet with all details to any YES answers above. |
| |
|
Declaration (Please Read Carefully)
I read and/or understand English. I have read the above
statements. I declare that the above information is true and complete to
the best of my knowledge and belief. Apart from the matters disclosed
above, I am in good health and ordinarily enjoy good health. In the event
of fraud, misstatements, concealment, or failure to disclose information
on this application, whether by intentional or inadvertent, any insurance
issued based upon this application may become void and no benefits will be
payable. Binding Arbitration - Waiver of Right to Trial by Jury: I
understand and agree that any disputes concerning this insurance must be
submitted to binding arbitration if the amounts in dispute exceeds the
jurisdictional limits of small claims court and is not resolved with a
formal review by Underwriters. I understand and agree that this is a
waiver of my and Underwriters rights to a trials by jury. I acknowledge
that I reside outside the United States for more than 5 months per year,
rendering me ineligible for coverage through standard medical
carriers.
Authorization
I hereby authorize any licensed physician, medical
practitioner, hospital, clinic or other medically related facility,
insurance company or other organization, institution or person that has
records or knowledge of me or my health, to give to the Petersen
International Underwriters.
Date ___________________ Signature of
Proposed Insured
_________________________________________
WC/5/01 |
