Medical Insurance Application


Applicant Name
First Name
Middle Name
Last Name
Sex
Date of Birth (dd/mm/yyyy)
Place of Birth
Profession (in details)
Registeration No.
Marital Status
Business Address
Home Address
E-mail Address
Mobile number
Business Phone
Home Phone
Heigth
Weight
Blood Type


Eligible Dependents
First NameMiddle NameLast NameDate of Birth (dd/mm/yyyy)Relationship HeightWeight
1.
2.
3.
4.
5.
6.
7.


Address where correspondance should be sent
Hospitalization Plan
IN-Patient Class
Select the cover
OutPatient Plan (AROPE Share 85%)


Answer below questions by using Yes or No. If your answer is yes, please give details by scrolling the cursor horizentally and vertically.
Heatlh Questionnaire
 InsuredWifeChild1Child2Child3Child4
Are you registerd or benefit from the National Security National Fund (NSSF)?
Are you or were you previously insured under a medical insurance plan with Arope Insurance or with other insurance company?
For female only : Are you pregnant? If yes, state the date of pregnancy and expected date of delivery.
Has your weight changed during the last year? why?
Do you consider yourself in good health and without chronic disease, bodily informity or handicap?
Do you drink alcohol? If yes, state your weekly consumption.
Are you a smoker? If yes, state your daily number of cigarettes.
Are you drugs addict?
Have you ever been told that you suffer from AIDS?
Do you have weakness in your five senses (vision or audition,...etc)?
Have you ever been treated for dermatology,gastro-intestional or contagious diseases?
Have you ever had an ECG, laboratory test, radiology tests, mri, scanner or other diagnostics tests? if yes state type of tests, date and medical center.
Have you ever been treated or operated for any disease or accidents? if yes state type of disease or surgery, date and hospital.
Are you now under medical control or about to undergo surgical operation soon?
Are you undertaking any medications on regular basis? if yes, state reason and duration.
Have you or any of your relations ever suffered from cardiacv disease, dvabetes, hypertension, cancer, nervous system disease, vascular disease or affecction of lungs, liver, kidneys....etc?
Do you exercise any hazardous sport or hobby?
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.