Individual Health Insurance Application

Comments

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

Proposed Insured

Name*

Spouse Gender*

Date*

Age Last Birthday*

Height*

Weight*

Number*

Phone*

Email*

Street Address*

City/Village*

District*

Employer*

Occupation*

Duties*

Are you a resident of Belize*

Yes

No

Are you a citizen of Belize*

Yes

No

Are you a citizen of any other country*

Yes

No

Country of Dual Citizenship

Type of Plan*

Annual Maximum*

Deductable*

Spouse

Name

Gender

Date

Age Last Birthday

Spouse Height

Spouse Weight

Spouse Social Security Number

Child

Row ID	Name	Gender	Date of Birth	Age Last Birthday	Height	Weight	Social Security Number	Actions

There are no Entries.

Authorization and Acknowledgement Statement

I hereby apply for health insurance to be issued solely and entirely in reliance upon the written answers to the foregoing questions and I agree that the insurance provided only covers the applicant and the dependants listed above who are accepted. I have read the answers to the questions before signing this application and the answers are correctly written as given by me to the best of my knowledge; true and complete.

The Company shall not be liable under this application until it has been received and approved, and the full first as premium stipulated is paid to RF&G Life Insurance Company. This policy shall be deemed to have effect as of the policy approval date. Information given in your application maybe made available to other Legal Insurance, Third Party Administrator (TPA), Re-Insurers & medical institutions upon request.

I understand that no Agent is authorized to make change nullify in any way any applicable coverage section of the policy or to suppress any of the Company’s requirement.

I hereby confirm that all expenses for Medical and Laboratory requirements requested by RF&G Life Insurance Company Limited will be fully paid by me if I choose not to accept the terms and conditions of the approved coverage. Also, I am aware and agree that an Administration Fee is payable by me if I choose not to accept the terms and conditions of the approved coverage.

DECLARATION: I hereby declare that all proposed Insured persons are domiciled in Belize for at least nine months and that my answers to medical questions asked in this application are answered truthfully and to the best of my knowledge. I also confirm that there are no known or ongoing illnesses that I am aware of.

Place

Date

Signature

Comments for the Insurer: OFFICIAL USE ONLY

Premium

Deductible

Requested Effective Date:*

For RF&G Life Insurance Company Limited

Signature

Date