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296 Herbert Macaulay Way, Sabo-Yaba, Lagos
Mon - Fri : 09:00 - 17:00
+234 1 448 9821; +234 703 000 9099
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HealthSupreme Registration Form-Family

HomeHealthSupreme Registration Form-Family
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HealthSupreme Enrollee Form (Family)
*Note: Kindly save all passport photograghs with the name of each beneficiary for ease of documentation (e.g Kunle Uche.jpg)
PAST MEDICAL HISTORY
Do you or any member of your family suffer (or had suffered) for any of the following ailment?If so indicate the name and condition(s) appropriately
Conditions
How did you hear about this product? (Select from the list below)
PLEASE INDICATE YOUR PREFERRED BENEFICIARIES FOR THE LIFE ASSURANCE COVER
NOMINATED BENEFICIARIES
S/NoNAMEDATE OF BIRTHRELATIONSHIPPROPORTION OF BENEFIT
×
(1)
MODE OF PAYMENT (select one)
DO YOU HAVE LIFE INSURANCE POLICY/POLICIES?
HAS ANY PROPOSAL ON YOUR LIFE EVER BEEN DECLINED, POSTPONED, DEFERRED, WITHDRAWN OR ACCEPTED ON SPECIAL TERMS?
Waiting Period & Limitations

  1. There is a waiting period of 14 days after receipt of your duly completed form and photographs before you can visit your hospital of choice.
  2. All non-emergency surgeries are subject to pre- authorization. 
  3. Maternity care: There is a waiting period of One (1) year after plan commencement before you can enjoy access to maternity care which is only available on family plans.
  4. Chronic conditions: These conditions such as hypertension, diabetes mellitus, bronchial asthma, etc, which cause you to be on regular prescribed medication, will only be covered after one year from date of diagnosis, provided that the illness started and was diagnosed while on the scheme

Terms of Subscription for individual plan

  

Plan Period: One year from commencement date, renewable yearly 

Eligibility: 0 - 50 years of age

Exclusions: The following conditions are not covered under the scheme:

a.   Medical services not included in selected plan. 
b.  Pre-existing conditions: any medical condition that existed prior to commencement date such as hypertension, diabetes, asthma etc. 
c.    Alternative medical treatment, nutritional supplements. 
d.    Cosmetic treatments. 
e.    Obesity, infertility,impotence, prosthesis, artificial limbs. 
f.   Major surgeries to head, spinal cord as well as organ transplants.
g.    Injuries resulting from Suicide attempts.
h.   Injuries resulting from Domestic violence. 
i.   Medical treatment outside Nigeria. 

Declaration
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