Health Declaration Form

Enrolment & Health Declaration Form

(Singapore Computer Society’s Voluntary Scheme)

WARNING: Pursuant to Section 25(5) of the Insurance Act, Cap 142 (Revised Edn 2000), you are to disclose in this enrolment form, fully and faithfully, all the facts which you know or ought to know, otherwise you may receive nothing from the policy.

Completed as a condition to the granting of insurance under Group Policy proposed by:

Name of Organisation:

COVERAGES      PLANS

(1) Living Protector S$50,000 S$100,000 S$150,000 S$200,000

(2) Hospital & Surgical Protector Plan 1 Plan 2 Plan 3 Plan 4

KINDLY COMPLETE FULLY IN BLOCK LETTERS AND INK. Any alteration in this form must be initialled.

(1) PARTICULARS OF LIFE TO BE ASSURED (MEMBER)

Full Name (As shown on IC - Underline Surname)

Sex    NRIC / FIN No    Member of SCS since

Occupation - Exact Duties    Height (cm)    Weight (kg)

Date of Birth    Contact Tel No

DEPENDANTS COVERAGE (ONLY FOR HOSPITAL & SURGICAL PROTECTOR): YES NO (If YES, please complete the highlighted portions in item (2) and (3) below.)

(2) DEPENDANTS’ INFORMATION

Relationship to Member     Name     NRIC / Birth Cert     Date of Birth DD MM YY     Height (cm)     Weight (kg)

Spouse

1st Child

2nd Child

3rd Child

(3) HEALTH QUESTIONNAIRE (Note: Dashes in pen or ditto cannot be accepted as replies. Please indicate ‘Yes’ or ‘No’)

Have you or has any person named in this form ever had or been told to have or been treated for:

Member Yes/No    Spouse Yes/No    1st Child Yes/No    2nd Child Yes/No    3rd Child Yes/No

a) Epilepsy, fits, stroke, paralysis, weakness of limb, prolonged headache, unconsciousness, nervous breakdown, depression, or any other nervous / mental disorders or disorders of the brain?

b) Diabetes, thyroid disorder or any other disorders of the endocrine system?

c) Ear discharge, nose bleeds, impaired sight, hearing or speech or any other disorders of the ear, eye, nose or throat?

d) Asthma, bloodspitting, persistent cough, pleurisy, tuberculosis or any other disorders of the lungs or respiratory system?

e) Raised cholesterol, high or low blood pressure, coronary artery disease, heart attack, rheumatic fever, palpitation, breathlessness, chest discomfort or pain, disease of or any other disorders of the heart or the blood vessels?

f) Jaundice, hepatitis or carrier, ulcer, hernia, chronic indigestion / diarrhoea, blood in stools, fistula, piles or any other disorders of the stomach, liver, gall bladder, intestines or digestive organ?

g) Protein, blood, pus or sugar in urine, renal stone or any other disorders of the kidney, bladder or genital organs?

h) Arthritis, slipped disc, recurrent back pain, gout or any other disorders of the muscle, spine, limbs or joints or severe injury?

i) Sexually transmitted diseases such as gonorrhoea, syphilis, non-specific urethritis, any other venereal disease, AIDS or AIDS related condition or infection with any Human Immunodeficiency Virus (HIV)?

j) Cancer, tumour, cyst, growth of any kind (please specify cancerous/non-cancerous and site of the growth/organ involved)?

k) Gynaecological disorders such as endometriosis, ovarian growth, fibroid, irregular menstrual bleeding, abnormal pap smear results etc?

l) Anaemia, any other disorders of the blood, congenital anomalies, physical defects or any other illnesses, disorders not mentioned above?

(4) Are you or is any person named in this form currently receiving or considering receiving medical attention, or taking addictive drugs? Yes No

(5) In the past 5 years, have you or has any person named in this form ever had a surgical operation or an X-ray examination, ultrasound, CT scan, biopsy, electrocardiogram (ECG), HIV-antibody, blood or urine test, or other medical tests carried out for investigative purpose? Yes No

(6) If any of the answers to Section (3), (4) & (5) is YES, please PROVIDE COMPLETE INFORMATION and MEDICAL REPORT. If necessary, please attach a separate sheet.

Question No    Name    Details of Diagnostic Tests / Diagnosis / Treatment / Operation    Date From   To    Name & Address of Doctor / Hospital

(7) Have you or your spouse smoked during the past 12 months? Yes No

If YES, please state the number of years you have been smoking and the number of sticks per day?

Number of Years:    Amount per day:

(8) Do you or your spouse consume beer, wine, alcohol or other stimulants? Yes No

If YES, please state quantity and frequency of consumption?

Quantity:    Frequency:

(9) Do you or does any person named in this form engage in activities which will increase the likelihood of exposure to any immunity disorder such as Aids or Aids Related Conditions. Yes No

If YES, please PROVIDE DETAILS.

(10) Have either of your natural parents or any siblings died or suffered from cancer, heart disease, stroke, high blood pressure, diabetes, kidney diseases, mental disorder or any hereditary disease? Yes No

If YES, please provide details below:

Relationship Diagnosis / Cause of Death Age At Diagnosis

(11) Have you or has any person named in this form ever had any health or life insurance application declined, postponed or accepted on special terms? Yes No

If YES, please PROVIDE FULL INFORMATION.

(12) Do you or does any person named in this form engage in hazardous activity or occupation such as flying, scuba / skin diving, motor racing, etc.? Yes No

If YES, please PROVIDE DETAILS such as locations, frequency, etc.

Declaration

I / We declare that the information given above is true and complete. I / We agree that this application shall be the basis of the contract of insurance to be issued under the said Group Insurance Policy. I / We understand the Insurance shall not become effective until it is accepted and confirmed in writing by The Asia Life Assurance Society Limited.

I / We consent to The Asia Life Assurance Society Limited seeking information from any doctor who has attended to me / us or from other insurance company to which I / we have at any time made a proposal for insurance and I / we authorize the giving of such information. I / we further authorize The Asia Life Assurance Society Limited to give such information obtained or information contained here for the purpose of obtaining insurance cover under the said Group Policy to your adviser / administrator of the said Group Insurance Policy.

If a material fact is not disclosed in this enrolment form, any policy issued may not be valid. If you are in doubt as to whether a fact is material, you are advised to disclose it. This includes any information that you may have provided to your adviser but was not included here. Please check to ensure you are fully satisfied with the information declared in this enrolment form.

I / We confirm that I / We have read and understood the contents of (1) “Your Guide to Health Insurance” and (2) “Product Summary”.