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Underwriter)
DATE RECEIVED
Maxicare EFFECTIVE DATE
ID NUMBER
HE Healthcare Corporation EMPLOYEE NO
CORPORATE CODE
CORPORATE NAME
PART 1
NOTE: TO FACILITATE PROCESSING OF THIS APPLICATION, PLEASE ACCOMPLISH THIS FORM IN FULL. KINDLY WRITE IN BLOCK LETTERS AND
APPLICANT INFORMATION
CHECK THE APPROPRIATE BOX WHERE APPLICABLE.
NOTE: TO FACILITATE PROCESSING OF THIS APPLICATION, PLEASE ACCOMPLISH THIS FORM IN FULL. KINDLY WRITE IN BLOCK LETTERS AND CHECK THE
APPROPRIATE BOX WHERE APPLICABLE
NEW APPLICANT ADDITIONAL APPLICANT REAPPLICATION
TRANSFEREE
INDIVIDUAL FAMILY GROUP/CORPORATE SPECIFY NAME:
TYPE OF COVERAGE _________________________________________________
PRINCIPAL/PAYOR
LASTNAME FIRSTNAME MIDDLE INITIAL DATE OF BIRTH (M-D-Y) AGE BLOOD PRESSURE
CIVIL STATUS NATIONALITY HEIGHT (FT. IN.) WEIGHT (LBS) SEX TIN NO.
CONTACT PERSON & MAILING ADDRESS (NUMBER, STREET, VILLAGE, BRGY, CITY, ZIP CODE) OFFICE PHONE NO: FAX NO:
(IF UNDER AN AGENT/BROKER PLEASE INDICATE AGENTS/BROKERS ADDRESS)
YOUR SPOUSE
PROPOSED MEMBERS
YE NO YE NO
S S
YE NO YE NO
S S
YE NO YE NO
S S
YE NO YE NO
S S
YE NO YE NO
S S
YE NO YE NO
S S
FOR FAMILY AND GROUP ACCOUNTS: 2 UP TO 21 YEARS OLD ARE ACCEPTABLE AGES FOR MINOR DEPENDENTS. CHILDREN WHO ARE 22
YEARS OLD AND ABOVE WILL BE CONSIDERED AS INDIVIDUAL APPLICANTS.
1e The genito-urinary system – such as renal colic, stone, bladder or kidney disorder, stricture, prostate disorder,
. syphilis, or venereal disease, etc.?
1f. The metabolic system – such as diabetes, gout, thyroid or adrenal disorder etc. and immune system disorders
including acquired immune deficiency syndrome (AIDS), AIDS-related complex (ARC) etc.?
1g The musculo-skeletal system – such as back sprain, neck or back disorder arthritis, fractures, slipped disc,
. dislocation, joint problems, physically handicapped, etc.?
1h The respiratory tract – such as asthma, tuberculosis, spitting or coughing blood, allergies, emphysema, lung/chest
. disease of any kind, etc.?
2 Has any proposed member/s ever received a medical advice or treatment for, or ever had any known
. indications of any breast condition, infertility or other female problems?
3 So far as you know, is a proposed member/s now pregnant?
. Expected delivery date: (M-D-Y) __________________________
3a If YES, is caesarean section anticipated?
.
4 Has any proposed member/s ever received medical advice or treatment for:
.
4a Disease of eyes, ears, nose or throat?
.
4b Any skin disorders, cancer, psoriasis, keratosis, herpes, etc.?
.
4c Cancer?
.
4d Tumor?
.
4e Alcoholism or drug dependency?
.
4f. If YES to 4e, is he a member of a support group?
5 Has any proposed member/s ever had any:
.
5a Hospitalization/Surgery?
. If YES, please give details
____________________________________________________________________________________________
6 Any congenital disorders?
.