Group Health & Group Life Application

Agent Email

Section 1: Employee Information

Name of Employer:*

Date of Employment:*

Name of Employee:*

Date of Birth:*

Age:*

Place of Birth:*

Height (feet)*

(inches)*

Weight(lbs):*

Gender:*

Social Security #:*

Occupation & Duties*

Employee to be enrolled in:*

Group Health Insurance

Group Life Insurance

Critical Illness

Personal Accident

Type of Group Health Plan:*

Sum Insured (Group Life):*

Annual/Lifetime Max (Group Health):*

Deductible (Group Health):*

Additional Group Health Benefits:

Dental & Vision

Additional Group Life Benefits:

AD&D

TPD

Applying for (applicable to Group Health):*

Employee

Employee & Spouse

Employee & Child(ren)

Employee, Spouse & Child(ren)

Are you a resident of Belize?*

Yes

No

Are you a citizen of Belize?*

Yes

No

Are you a citizen of any other country other than Belize?*

Yes

No

Which other country are you a citizen of?

Section 2: Dependent Information

Complete for each person to be insured.

Dependents

Name	Relationship	Gender	Date of Birth	Social Security Number	Actions

There are no Dependents.

Section 3: Prior Insurance Coverage (if applicable)

Have you or your dependents been covered under any health insurance plan within the last 90 days?*

Yes

No

If, Yes, to qualify for prior coverage credit; please provide the following information on all coverage in force in the past 12 months.

Name of Insurance Company*

Ins. Co. Phone #

Effective date of Prior Coverage*

Termination Date (if applicable)*

Type of Coverage:*

Individual

Group

Policy No.:

Coverage was for (check all that apply)*

Self

Spouse

Children

Section 4 Health Declarations

(Answer the following truthfully. If yes to any, provide brief details.)

1. Are you and/or your dependents of sound health?*

Yes

No

2. Have you and/or your dependents been with or treated for any serious illness (e.g. heart disease, cancer, diabetes, ect)?*

Yes

No

3. Do you and/or your dependents hav any disability or ongoing medical condition?*

Yes

No

4. Are you and/or your dependents currently taking any prescribed medications?*

Yes

No

If yes to any question above, please provide medical details

Name of Inured	Date of Treatment	Medications & Dosages	Recovery Status	Please list any treatment, Surgery or Anticipated Surgery for this Condition	Medical Condition or Specific Reason for Treatment	Actions

There are no Entries.

Section 6 (Applicable to Group Life Insurance Coverage ONLY)

I, the undersigned request that in the event of my death, all proceeds from my Group Life Insurance policy be paid to:

Primary Beneficiary

Primary Beneficiary

Full Name Relationship Date of Birth Percent Address Actions

There are no Beneficiaries.

Maximum number of beneficiaries reached.

Contingent Beneficiary

Name
First Middle Last

Address
Street Address City State / Province / Region

Relationship

Date of Birth
MM slash DD slash YYYY

Percent

Trustee Information (for minors stated as beneficiaries)

Name
First Middle Last

Address
Street Address City State / Province / Region

Relationship

Date of Birth
MM slash DD slash YYYY

Percent