HealthSupreme Registration Form-Individual

HealthSupreme Enrollee Form (Individual)

SCRATCH CARD PINinsert valid pin

SCRATCH CARD SERIAL NO.insert valid serial number

Passport Photographupload

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NameFull Name

Addressyour home address

Phone

Company

Designation

Emaila valid email

D.O.Bdd/mm/yy

Allergies

Hospital of Choice

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

If others, specify

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If yes, what type of surgery was it and when?

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Please state any other relevant information you would like us to have concerning your health?

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If others, specify:

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Name of contact person from the selected company:

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PLEASE INDICATE YOUR PREFERRED BENEFICIARIES FOR THE LIFE ASSURANCE COVER

NOMINATED BENEFICIARIES

S/No	NAME	DATE OF BIRTH	RELATIONSHIP	PROPORTION OF BENEFIT
					×

(1)

DO YOU HAVE LIFE INSURANCE POLICY/POLICIES?

YesNo

IF YES, NAME OF INSURER:

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TOTAL SUM ASSURED:

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HAS ANY PROPOSAL ON YOUR LIFE EVER BEEN DECLINED, POSTPONED, DEFERRED, WITHDRAWN OR ACCEPTED ON SPECIAL TERMS?

YesNo

IF YES, GIVE DETAILS:

0 /

Waiting Period & Limitations

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.
All non-emergency surgeries are subject to pre- authorization.
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.
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 followingconditions 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

I hereby declare that all information given above are true to the best of my knowledge and that I have not concealed or withheld any information. I have also read and understood the above and declare that the terms are acceptable to me. I agree that HCI Healthcare Limited and it's partners shall not be liable for any claims that arise from conditions or treatments contrary to the above terms. I authorize any medical practitioner or organization having medical information concerning me/us to provide such information to HCI Healthcare Limited.

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HealthSupreme Registration Form-Individual

Terms of Subscription for individual plan

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