Life Insurance Application


Applicant Name
First Name
Middle Name
Last Name
Sex
Date of Birth
Place of Birth
Register No.
Marital Status
Profession (details)
Business Address
Home Address
Email address
Mobile number
Business Phone
Home Phone
Address where correspondance should be sent
Nationality
Choose your Cover Plan
Life
Total Permenant Disability
Sum Insured
Duration
Weight (kg)
Height (cm)


Details about beneficiary
First NameMiddle NameLast NameRelationPercentage
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Answer below questions by using Yes or No. If your answer is yes, please give details.
Has your weight ever changed during the last year, why?
Do you consider yourself in a good health with no chronic disease, handicap, bodily defect or deformity?
Are you undertaking any medications on regular basis? if yes, give reason and duration.
Did you ever have any operation, accident, injury or been hospitalized for a disease?
Have you ever suffered from skin, gasro-intestinal or contagious diseases?
Are you or have been drug addict?
Have you ever been told that you suffer from AIDS?
Do you exercise any hazardous sport or hobby?
Do you haveweakness in your five senses(vision, audition....etc)?
Have you ever had an electro-cardiograph, lab test, X-ray, MRI, Scanner or other diagnostic tests within the last 5 years?
Do you drink alcohol?if yes state the weekly consumption.
Are you a smoker ? if yes state the number of cigarettes per day
Have you been absent from your work on grounds of poor health during the last 2 years?
Did you consult a doctor within the last 5 years and for what complaint?
State name, address and specially of your medical attendant ?
Do you have another life and/or PA Policy with Arope Insurance or other insurance company? if yeas state name of compnay, sum insured and expiry date.
Company NameSum InsuredExpiry Date (dd/mm/yyyy)
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Has an application of an insurance (Life, Personal Accident, Hospitalization) ever been declined, deferred, withdrawn or accepted with a loading or on special terms?
Did any of your relatives died as a result of specific disease?
Have you or any of your relatives ever suffered from any of the following: Asthma, Pleuristy, Diabets, Hypertension, Cancer, Epelipsy, Tumor, Brain Diseases, Tuberculosis, affection of lungs, liver, kidney or bladder, heart vascular, blood vessels diseases, nervous or mental disorder...etc ?
I declare that the above statements and answers are true in every particular way and agree that this statement and declaration (recto-verso) shall be the basis of contract between me and AROPE Insurance s.a.l. and that if any untrue avernment be contained therein, the contract of assurance shall be absolutely null and void and all the money which have been paid thereof shall be forfeited respectively.
I further agree that the assurance shall be considered in force when a policy has been issued and signed, and the first premium paid thereon.
I consent to the Company, making inquiries at all times about medical personel who may I have attended or shall attend and hereby authorise such medical personel to give unreservedly such information as the Company may require.