• 4th Floor Gordon House, 1 Coney Drive
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Questionnaire For Infant & Young Children

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  • Questionnaire For Infant & Young Children

Infants & Young Children

"*" indicates required fields

This field is for validation purposes and should be left unchanged.

Questionnaire is to be filled out for each child between 0 – 12 years old.

Name of Insured*
Name of Child:*

All questions are to be answered for each child to be covered.

1. Does the child have any evidence of/or was diagnosed with any congenital or genetic abnormality?
2. Are the parents known to have any genetic abnormality which may later become evident in the child?
3. Were the usual milestones of early childhood reached at the expected times?
4. Is the child at present thriving and in good health?
6. Has the child ever been in hospital or referred to a consultant for any reason?

For children up to age three (3) years.

1. Was the child delivered at full term? If not, state gestational age
2. Were there any complications at childbirth?
4. Has the normal immunization program been carried out?
Date

RF&G%20Life%20Insurance

Main Office:
4th Floor Gordon House, 1 Coney Drive
P.O. Box 1762, Belize City, Belize C.A.31 Guadalupe street, San Ignacio

Orange Walk Office:
23 Belize Corozal Road, Orange Walk Town

Corozal Office:
4 Park Street North, Corozal Town

221-5143
671-5143
info@rfglife.com

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