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APEX -dependents application form

The document is a Dependant Form for APEX Health Insurance, requiring personal and medical information from the applicant. It includes sections for the applicant's name, date of birth, gender, relationship, and medical history, along with benefit options to select from. The form concludes with a declaration section for both the applicant and the Human Resource Manager to confirm the accuracy of the provided information.

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05445524408h
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3 views

APEX -dependents application form

The document is a Dependant Form for APEX Health Insurance, requiring personal and medical information from the applicant. It includes sections for the applicant's name, date of birth, gender, relationship, and medical history, along with benefit options to select from. The form concludes with a declaration section for both the applicant and the Human Resource Manager to confirm the accuracy of the provided information.

Uploaded by

05445524408h
Copyright
© © All Rights Reserved
We take content rights seriously. If you suspect this is your content, claim it here.
Available Formats
Download as PDF, TXT or read online on Scribd
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APEX HEALTH INSURANCE

Zion House, East Legon. P.O. Box ST 237 Accra, Ghana


Tel: 0302 54 25 54 PHOTO
Website: www.apexhealthghana.com

DEPENDANT FORM Please staple


MEMBERSHIP BENEFITS NUMBER: FOR OFFICE USE ONLY ends only

Please fill in capital letters

SURNAME FIRST NAME MIDDLE NAME

DATE OF BIRTH GENDER RELATIONSHIP NHIS NUMBER


DD MM YY MALE FEMALE

TEL: PRINCIPAL MEMBER:

BENEFIT OPTIONS (Please Tick)

BRONZE SILVER GOLD PLATINUM

MEDICAL HISTORY (Please Underline or Circle the appropriate Medical Condition applicable to you)
45.Severe recurrent
1.Allergies 12.Cystic Fibrosis 23.HIV positive 34.Leukemia diarrhea
13.Depression or Psychiatric 35Life insurance
2.Anemia disorder 24.Heart attack rejected 46.Smoking
47.Spectacles or
3.Angina 14.Diabetes Mellitus 25.Heart disease 36.Liver condition contact lenses
15.Disorder of the digestive
4.Asthma system 26.Hepatitis 37.Lung disease 48.Stroke

5.Back Neck Joint Problems 16.Embolism 27.Hepatitis B 38.Malaise 49.Thrombosis


39.Malignant
6.Benign cancer 17.Emphysema 28.Hernia cancer 50.Thyroid disorder

7.Bladder Infections 18.Endocrine disorder 29.Hypertension 40.Migraine 51.Tuberculosis


30.High Cholesterol 41.Nephritis
8.Chronic Bronchitis 19.Epilepsy Level 42. On Medication 52.Ulcers
53.Varicose Vein
9.Congenital Heart 43. Rheumatic 54. Pregnancy
Abnormalities 20.Fibroid 31.Intestinal Fibrosis Arthritis
55.No specific
10.Congenital kidney disorder 21.Gall bladder disease 32.Jaundice 44. Sickle Cell risks

11.Gout 22.Kidney stone 33.Rheumatic Fever

Kindly provide details for option(s) ticked :


………………………………………………………………………………………………………………………………………….

Others- Please State: ……………………………………………………………………………………………………………………………………………………………..


DECLARATION

APPLICANT HUMAN RESOURCE MANAGER,


I HEREBY DECLARE THAT THE INFORMATION I HEREBY CONFIRM THAT THE DETAILS GIVEN
I HAVE GIVEN ABOUT ME AND MY DEPENDANTS ARE TRUE. BY THE APPLICANT ARE TRUE
SIGNATURE____________________________ SIGNATURE____________________________

DATE________________________________ DATE_________________________________

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