MARSH PNG MEDICARE SCHEME

MEDICAL PERSONAL ACCIDENT LIFE INSURANCE

APPLICATION FORM
Please complete the application form in order to assess Medical, Personal Accident & Life insurance coverage or advise changes
to the insurer on your existing policy. Failure to complete this form correctly could result in loss of refunds under these insurance
policies issued by PMMI.
1. INSTRUCTION
(tick the box in the next column)

New Member

Change my Policy Details

Date:
2. PLEASE PROVIDE YOUR PERSONAL DETAILS
Surname:

Christian Name(s):

Mobile Contact No:

Nationality:

Work Place Contact No:

Date of Birth:

Work Place Fax No. or Email:

Name of Spouse or next of kin Name:

Employers Name & Address:

Your spouse or next of kin contact

no. or address:

Gender:

Male

Female

Your Age at next Birthday:

Civil Status:

Single

Defacto

Married

Widowed

Divorced / Separated /
Single Parent

Number of Dependants declared on this application:

3. EMPLOYMENT DETAILS

New Member Details

Position:

Location:

Payroll Number:

Full-time/Part-time:

Change my Policy Details

Commencement Date:
This policy insures your 5 Dependant children up to 18 years or 25 years, unmarried and attending tertiary institutions. Student
proof is required for your dependants 18 years up to 25 years. Natural parents of the contributing member is insured subject to
declaration on this form.

4. MEDICAL COVER DEPENDANTS DETAILS

Dependant Name

Date of Birth

Gender

1.
2.
3.
4.
5.
Natural Parents Details:
6.
7.

New Member Details

Change my Policy Details

Current Age

Relationship to YOU, the Life

Insured

Proof of
Studentship
attached

5. LIFE COVER BENEFICIARIES DETAILS

Name of Beneficiary

Date of Birth

Gender

New Member Details

Change my Policy Details

Current Age

% of Benefit

1.
2.
3.
4.
5.
6.
7.
8.
9.
10.

Relationship
to YOU, the
Life Insured

6. MEDICAL HISTORY DECLARATION

New Member Details

Change my Policy Details

My usual Doctor or Physicians name is:

Address:

Phone:

Fax:
YES

1.

Has any member of your family had medical treatment?

When was the date of this last visit?

2.

Do you or any of the persons to be insured have Medical Insurance with us or any other Insurance company in PNG?
Have you held a Medical Insurance Policy with other company prior to this application?
Have you or your dependents Application for medical insurance, ever been declined, restricted or accepted at other than normal
terms?
If Yes, please state reason and provide the name of the Insurance Company.

3.

4.

Have you or any of the persons to be insured;

a.

Suffered or have any physical defect, infirmity, or con genital conditions?

b.

Currently under observation or receiving treatment or taking any medication?

c.

Ever been advised to have a surgical operation which has not been performed?

Have you or any of the persons to be insured ever been told that you or them suffered from
a.

Chronic cough, spitting blood, ashma, hay fever, pleurisy, tuberculosis or any other disease of the respiratory system?

b.

High or low blood pressure, heart disease, chest pain, heart attack, shortness of Breath, Palpitations or any other disorder of
the heart or blood vessels?

c.

Epilepsy fits, dizziness, mental or nervous disorder?

d.

Diabetes, sugar or blood in urine, kidney, colic or hernia?

e.

Disease of the eyes, ears, nose or throat?

NO

If YES, please provide details:

f.

Arthritis, sciatica, rheumatism, back, spine, bone joint, muscle or skin disorder?

g.

Ulcer or disorder or the stomach, intestines, hemorrhoids or rectal disorder?

h.

Gall bladders stone or liver disease or any type of hepatitis?

i.

Cancer, tumor or growth of any kind or any organ system?

j.

Anaemia, Thyroid disorder (such as Goitre) or Rheumatic Fever?

k.

Sexually transmitted diseases such as syphilis, Gonorrhea or non-specific urethritic?

l.

HIV, AIDS or AIDS related conditions?

m. Any illness, disease or injury not mentioned above?

5.

Is there anything in your health, occupation, personal history, or family history, or family history which may render the proposed
assurance more than usually hazardous? If so, please give details.

6.

Have you any intention of engaging in any pursuit which may be considered hazardous, e.g. motor-racing, mountaineering,
etc?

7.

Have you any intention of:

(a) Going abroad otherwise than for short holidays?
(b) Flying or travelling by air otherwise than as a fare-paying passenger on a recognized air service?
(c) Serving in the Navy, Army, Air Force or any Auxiliary or Reserve?

8.

Are you at present, to the best of your knowledge, in good health?

9.

Have you consulted a doctor during the past two years? If so, please give details and dates

10.

Please give accurate details of your height and weight:

Height (in shoes)

cm

Weight (in ordinary indoor clothes)

kg

Date when taken (preferably within the last month)

YES
11
.

NO

If, Yes please provide details

Has your usual medical attendant or any other doctor ever: (If yes, please give full details and dates)
(a) Sent you to see a Consultant or Specialist?
(b) Sent you to a hospital or nursing home, either as an in-patient or as an out-patient?
(c) Kept you in bed or away from work for more than a week at a time?

12
.

Have you ever had a chest x-ray?

Are you about to have a chest x-ray?
Have you ever had an x-ray for any other complaint or illness?
Are you about to have such an x-ray?

13
.

Have you or any near relatives suffered from nervous disorders, epilepsy, diabetes, stroke, heart disease or
tuberculosis disease?

14
.

What is your average daily consumption of:

15
.

Information relating to members of your family:

If living, Age

(a)

Alcoholic beverages?

(a)

(b)

Tobacco?

(b)

Present State of health

If dead, Age at time of death

Father

Mother

Brothers
(if none, please say so)
Sisters
(if none, please say so)

Cause of death

Year of Death

DECLARATION
I/We hereby declare that the above answers and statements are true, and that I/We have withheld no information whatever
regarding this proposal. I/We agree that this Declaration and answers given above, as well as any proposal or declaration or
statement made in writing by me/ourselves or any one acting on my/our behalf shall form the basis of the contract between
me/ourselves. I/We hereby further declare that I/We agree that in the event the declaration shall contain any misstatement,
misrepresentations, suppression and/or fraud, the insurance of the policy shall not be nor deemed to be a waiver of such
misstatement, misrepresentation, suppression and/or fraud.
I/We hereby authorise any hospital, surgeon, medical practitioner or clinic or other person who attended to me/us for any reason
to disclose to the Insurance Company any and all information with respect to any illness or injury and to provide copies of all
hospital and medical records/certifications, including any earlier medical history. I/We acknowledge that the liability of the
Insurance Company does not commence until this proposal is accepted by and premium paid to the Insurance Company.

Signature of Principal
Insured Member

Date

Month

Year

INTERNAL ONLY
TO BE COMPLETED BY MARSH MEPAL TEAM
LODGEMENT DETAILS
Date Lodged with Marsh:

Day

Month

Year

Application received &

checked for accuracy by
whom:

Data Entered by Whom in MEPAL Scheme:

Day

Month

Year

Membership processed
by who:

Date Advised to PMMI:

Day

Month

Year

PMMI Advised on new

member, note known
pre-existing conditions
and confirm cover by
who: