PLAN TYPE Boss LifePremium LifeLife PlusCoupleLife Starter

COVER TYPE Self OnlySelf & Spouse/PartnerSelf, Spouse/Partner & Children

If buying this plan for someone other than yourself, kindly fill in your details here:

[cf7mls_step cf7mls_step-1 "Next" ""] PRINCIPAL MEMBER DETAILS

Upload Passport Photo [cf7mls_step cf7mls_step-2 "Back" "Next" "Step 2"]SPOUSE/PARTNER DETAILS

Upload Passport Photo [cf7mls_step cf7mls_step-3 "Back" "Next" "Step 3"] CHILD 1 DETAILS

Upload Passport Photo

CHILD 2 DETAILS

Upload Passport Photo

CHILD 3 DETAILS

Upload Passport Photo

CHILD 4 DETAILS

Upload Passport Photo [cf7mls_step cf7mls_step-4 "Back" "Next" "Step 4"] MEDICAL CONDITIONS (Please select appropriate answer) Do you have / have you suffered from any of the underlisted conditions

Chest pain / Angina or heart attack?

PrincipalSpouseChild 1Child 2Child 3Child 4

High blood pressure (hypertension)?

PrincipalSpouseChild 1Child 2Child 3Child 4

Lung/respiratory condition e.g. asthma, bronchitis, emphysema?

PrincipalSpouseChild 1Child 2Child 3Child 4

Stomach/bowel disorder e.g. peptic ulcer or diverticulitis or ulcerative colitis?

PrincipalSpouseChild 1Child 2Child 3Child 4

Urinary or kidney disorder e.g. kidney stones, urine incontinence, recurring urinary tract infections, or any requiring dialysis?

PrincipalSpouseChild 1Child 2Child 3Child 4

Muscle/bone or joint disorder e.g. bone fractures, osteoporosis, gout, or arthritis?

PrincipalSpouseChild 1Child 2Child 3Child 4

Diabetes which is controlled by insulin drugs and/or diet?

PrincipalSpouseChild 1Child 2Child 3Child 4

Prostrate disorder?

PrincipalSpouseChild 1Child 2Child 3Child 4

Epilepsy or seizures?

PrincipalSpouseChild 1Child 2Child 3Child 4

Depression or schizophrenia or bipolar or other mental health conditions or drug or/and alcohol dependency?

PrincipalSpouseChild 1Child 2Child 3Child 4

Blood disorder e.g. sickle cell anemia or thalassemias or G6PD?

PrincipalSpouseChild 1Child 2Child 3Child 4

Disease of the eye or nose or throat lasting longer than six months?

PrincipalSpouseChild 1Child 2Child 3Child 4

If yes, please give details:

Cancer that has been partially or totally threated?

PrincipalSpouseChild 1Child 2Child 3Child 4

Congenital adnormalities?

PrincipalSpouseChild 1Child 2Child 3Child 4

[cf7mls_step cf7mls_step-5 "Back" "Next" "Step 5"] SURGICAL HISTORY (Please tick appropriate answer) Have you suffered from any condition requiring, or have been recommended for surgery in the last twelve months?

PrincipalSpouseChild 1Child 2Child 3Child 4

[cf7mls_step cf7mls_step-6 "Back" "Next" "Step 6"] GENERAL QUESTIONS (Please tick appropriate answer)

Have you tested positive for HIV/AIDS?

PrincipalSpouseChild 1Child 2Child 3Child 4

Have you experienced any of the following unexplained weakness, weight loss, diarrhea, skin lesions or enlarged nymph nodes?

PrincipalSpouseChild 1Child 2Child 3Child 4

Do you take any prescription medications for periods longer than one month?

PrincipalSpouseChild 1Child 2Child 3Child 4

If yes, please explain?

Has there been any change in any of your prescription dosage/s?

PrincipalSpouseChild 1Child 2Child 3Child 4

If yes, please explain?

Have you received any new prescription, investigation or new medical consultation in the last 6 months?

PrincipalSpouseChild 1Child 2Child 3Child 4

Have you ever been tested or treated for infertility?

PrincipalSpouseChild 1Child 2Child 3Child 4

[cf7mls_step cf7mls_step-7 "Back" "Next" "Step 7"] FOR FEMALES ONLY

Are you pregnant?

YesNo

When was your last pregnancy?

Any pregnancy complications? Please tick any that pertains to you:

Miscarriage

YesNo

Still Birth

YesNo

Difficult child delivery

YesNo

Any history of irregular menstrual cycle?

YesNo

Any history of gynecologic procedures or surgery?

YesNo

If yes, please give details:

[cf7mls_step cf7mls_step-8 "Back" "Step 8"]

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