Medical Insurance for Domestic Helper Proposal Form Step 1 of 2 50% Details of Alliens EmployeeName* Marital Status---SingleMarriedDivorced/SeparatedWidowerDate of Birth* DD slash MM slash YYYY Sex* Height* Weight* Residence Address*Workplace addressOccupation / Type of Work* Telephone MPΝo. Allien Reg. Νο Period of insuranceFrom:* DD slash MM slash YYYY To:* DD slash MM slash YYYY Contracting Party (Employer's) DetailsName* Identity Card No Company Reg No Employer Registry Number Postal Address*Telephone* Email* Medical History of Allien Employee1 Do you suffer from any disability or disc disease or hernia or varicose veins or reduction in vision or hearing or any other chronic disease? 2 Have you ever had a surgical operation or have you ever suffered from any disease or condition for which you had been advised that you may have to undergo surgery in the future? 3 Do you suffer from any disease or illness or do you have any symptoms? (In case of pregnancy, please note the Estimated Due Date) 4 In the last five years were you an inpatient in a hospital or clinic? Have you been to see a specialist? Did you visit your doctor or any other doctor? If any of the above was yes please give detailsOther Particulars5. Please provide the name and address of your medical doctor, and state how long you have known them.6 Has any Proposal you submitted for Life or Accident or Medical costs or Illness Insurance been rejected or accepted with restricted terms or has any Insurance company ever cancelled or refused to renew your insurance Policy or has imposed special terms? 7 Have you ever submitted a claim under an Accident or Illness or Medical costs Insurance Policy? 8 Do you currently have Accident or Illness or Medical costs insurance? 9 Have you received or do you receive any compensation from your employer or any fund for medical costs? If any of the above was yes please give details10.Please provide full details of your overseas trips, including countries, frequency and duration.11. Please provide full details of any sports activities you undertake.For Data Protection Company Policy Click Here. * I have read the Data Protection Company Policy posted on this website I herewith provide Royal Insurance Company Ltd (and any successors and assignees thereof), my express and unconditional consent regarding the processing and creation of data records in electronic and physical form, of all my relevant personal data, that may include sensitive data which I have declared and submitted
