Group Health & Group Life Application

Step 1 of 6

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Agent Email

Section 1: Employee Information

Name of Employer:*

Date of Employment:*

MM slash DD slash YYYY

Name of Employee:*

Date of Birth:*

MM slash DD slash YYYY

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

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

Are you a citizen of Belize?*

Yes

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

Yes

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.

Maximum number of dependents reached.

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

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*

MM slash DD slash YYYY

Termination Date (if applicable)*

MM slash DD slash YYYY

Type of Coverage:*

Individual

Group

Policy No.:*

Coverage was for (check all that apply)*

Self

Spouse

Children

Section 4 Medical Information

Brain or Nervous System*

Yes

Thyroid or Pituitary Disorder*

Yes

Nervous, Mental or Emotional Disorder*

Yes

Diabetes or Sugar in Urine*

Yes

Drug or Alcohol Abuse*

Yes

Disease of the Muscle*

Yes

Epilepsy or Cerebral Palsy*

Yes

Bone or Joint Disorder*

Yes

Abnormal Blood Pressure*

Yes

Arthritis, Rheumatism, Bursitis*

Yes

Heart or Circulatory System*

Yes

Disorders of Back or Spine*

Yes

Chest Pain or Stroke*

Yes

Lungs or Respiratory System*

Yes

Blood Disorder or Varicose Veins*

Yes

Emphysema, Tuberculosis, Chronic Obstructive*

Yes

Digestive or Gastrointestinal Tract*

Yes

Pulmonary Disease or Asthma*

Yes

Cirrhosis or Hepatitis*

Yes

Multiple Sclerosis or Cystic Fibrosis*

Yes

Rectum, Prostate or Hernia*

Yes

Liver, Pancreas or Kidney*

Yes

Skin or Collagen Disease*

Yes

Cancer, Leukemia or Hodgkin's Disease*

Yes

Genitourinary System*

Yes

Lymphatic Vessels or Glands*

Yes

Breast or Reproductive Organs*

Yes

Any Physical Deformity or Defect*

Yes

Endocrine or Adrenal Disorder*

Yes

2. Has anyone applying been diagnosed as having or been treated for human immunodeficiency virus (HIV) infection or any other acquired immune deficiency syndrome (AIDS) or AIDS related complex (ARC), significant weight loss, chronic fatigue or diarrhea, night sweats or enlarged glands?*

Yes

3. Are you or any dependent (whether applying for coverage or not) currently pregnant, anticipating surgery or is anyone applying for coverage disabled, restricted or unable to perform the normal activities of daily living and self-care?*

Yes

4. During the past 5 years, has anyone applying for coverage visited a doctor, had a medical consultation, had surgery, or been hospitalized?*

Yes

5. Is anyone currently taking medication?*

Yes

6. Is there any existing medical condition or problem, including any undiagnosed symptoms that have not otherwise been indicated on this application? For "yes" answer provide details below.*

Yes

Use this space to give details to any “Yes” answer to questions 1 through 6. If taking medication for high blood pressure, please included you last 3 blood pressure readings.

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.

Maximum number of entries reached.

Section 5

To be answered by the employee. If any of these questions are answered “Yes”, give complete details.

A. Have you or do you intend to engage in hand gliding, parachuting, Vehicle racing, skin or scuba diving or any other hazardous sport or hobby?*

Yes

Please provide details*

B. Have you or do you intend to fly other than as a passenger?*

Yes

Please provide details*

(i) Over the last 6 months have you done more than 50 sets of Flying as a passenger?*

Yes

Please provide details*

C. Do you smoke cigarettes, cigarillos, cigars or a pipe? (If yes, indicate how many per day of each).*

Yes

Please provide details*

D. Have you ever been a cigarette smoker in the past? (If yes, indicate how many cigarettes per day, and when and why you quit).

Yes

Please provide details*

E. Have you ever been told to quit cigarette smoking for Medical reasons? (Give details and name of physicians).*

Yes

Please provide details*

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

Section 7
Place*
Place
Date*
MM slash DD slash YYYY

Date
Signature*
Signature

Official Use Only
Effective Date of Coverage*
MM slash DD slash YYYY

Effective Date of Coverage
Approved By*
Approved By
Date*
MM slash DD slash YYYY

Date
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