APPLICATION FOR CANCER INSURANCE
 
SECTION A - PRIMARY INSURED
Insurance History (Insurance in-force on the life of Proposed Insured
Is the policy applied for intended to replace any existing insurance with NetCare or with any other companies?
SECTION B – COVERED SPOUSE (For Two Parent Family Plan)
SECTION C – BENEFITS AND PREMIUM DETAILS
SECTION D – MEDICAL DECLARATIONS
(Please indicate complete details of "YES" answers (Indicate doctor’s name, address and contact nos.):
Proposed
Insured
Covered
Spouse
 
Dependents
1. What is your height? (Indicate in feet and inches)
2. What is your weight? (Indicate in lbs.)
Has/Have the Proposed Insured(s):
Press switches for YES/NO answer
3. Ever had any change in weight in the past year? If yes, how many pounds?
4. Ever had or been told to have, or had indication of, or sought consultation for:
 
 
 
   a. cancer, cyst, tumor, lumps/abnormal bodily growth, enlarged lymph nodes, skin lesions or any disorder of the skin?
   b. AIDS or HIV infection related condition, allergies, fainting, anemia or any blood disorder?
   c. unexplained symptoms of fatigue, weight loss, diarrhea, loss of appetite, or frequent severe headaches?
5. Ever had or been advised to have any diagnostic test or surgery in the past 5 years?
6. Are you now under observation or treatment, or currently taking any prescribed drugs or medications?
7. Family History: ever had any family member who suffered from cancer, tumor, AIDS or HIV infection, or any familial disease? Give relation, age at onset, age at death (if applicable) and nature of disease.
SECTION E – BENEFICIARIES OF PRIMARY INSURED (Please use beneficiary form and attach, if the space provided is not enough)

I/We hereby declare that all the foregoing statements, declarations, and answers in this application, together with those in any required medical examination, including HIV and other laboratory tests, questionnaire or amendments, are complete and true, and that NetCare Life and Health Insurance, believing them to be such, will rely and act on them, and that they shall form the basis of any insurance policy to be issued hereon, and which together with the policy, shall constitute the entire contract between parties thereto.

AUTHORIZATION TO OBTAIN AND DISCLOSE INFORMATION

I/We further authorize my/our employer/s, or any physician, medical practitioner, hospital, clinic or any medically related organization or person to furnish NetCare Life and Health Insurance with any information concerning my/our medical history, including diagnosis, treatment or prognosis with respect to any physical or mental condition, and other non-medical information, including information about drugs and alcoholism.

I/We understand the information obtained through this Authorization will be used by NetCare to determine my/our eligibility for insurance. Any information obtained will not be released by NetCare Life and Health Insurance to any person or organization EXCEPT to reinsuring companies, the Medical Information Bureau Inc., or other persons or organizations performing business or legal service in connection with my/our application, or as may be otherwise lawfully required, or as I may further authorize.

Signed this
Dated at
Signature of Proposed Insured
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Signature of Spouse
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