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General Information

Please complete the application as accurately as possible and disclose all material information requested using block letters. It is important to understand that failure to disclose information in this application may result in authorization requests being declined or claims being repudiated.

Material Information is Information that affects our decision to insure the insured on the terms and conditions in this policy.

“AN INDIVIDUAL WHO ASSISTS AN APPLICANT TO COMPLETE THIS PROPOSAL FORM FOR INSURANCE SHALL BE DEEMED TO HAVE DONE SO AS THE AGENT OF THE APPLICANT”

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e.g Passport of the Main member (Max file size: 2MB)
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Contact address must contain House No. and street name (i.e 7, Kufo street), Area, LGA and state
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e.g Driver's License, National ID Card, International Passport(Max file size: 2MB)
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Family Physician and/or Primary Health Care Provider with applicant’s complete record:

Choice of Hospital on the scheme:

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Dependents Details

How many kids do you have?

Add your beneficiary(ies) details below .

**Please label the uploaded passport with the name of the Child where neccesary

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e.g Please upload passport sized photo (Max file size: 2MB)
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e.g Please upload passport sized photo (Max file size: 2MB)
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e.g Please upload passport sized photo (Max file size: 2MB)
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e.g Please upload passport sized photo (Max file size: 2MB)
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e.g Please upload passport sized photo(Max file size: 2MB)
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Medical History

Note: Pre-Existing Medical Conditions or Chronic conditions are not covered.

Chronic or Pre-existing medical condition is defined as an injury, illness, sickness, disease or other physical, medical, mental or nervous condition, disorder or ailment that with reasonable medical certainty existed at the time of purchase of the policy or prior to the purchase of the policy. Whether or not previously manifested, symptomatic, diagnosed, treated prior to the effective date, including any chronic or recurring complications or consequences related to or arising from such ailment.

“Tick those condition(s) to which your answer is yes (leave others blank).”

S/N Medical Condition Diagnosis/Medical Indications (Symptoms/Signs) P S C1 C2 C3 C4
1 Blood disorders e.g. anaemia, leukaemia, hemoglobinopathies (e.g. Sicklecell disease or traits, thalassemia), bleeding disorders,haemophilia, lymphoma, thrombosis (blood clots)
2 Brain and nerve disorders e.g. stroke, multiple sclerosis, epilepsy, migraine, paralysis,Parkinson’s disease, quadriplegia, paraplegia.
3 Cancer e.g. any form of cancer or pre-cancerous growth, tumours ormoles that have changed in appearance.
4 Cardiac and vascular disorders e.g. angina/heart attack, heart failure, heart murmurs,rheumatic fever, high blood pressure, rhythm disturbance(palpitations), varicose veins (including haemorrhoids/piles),poor circulation, raised cholesterol, heart surgery.
5 Connective tissue disorders e.g. SLE (systemic lupus erythematosus), scleroderma,mixed connective tissue disorder.
6 Dental disorders e.g. over/under bite problems, missing/skew teeth, impactedwisdom teeth or ongoing treatment.
7 Ear, nose, throat, eye and speech disorders e.g. cataracts, glaucoma, macular degeneration,hearing/visual impairment, loss of speech, tonsillitis.
8 Female/male reproductive system disorders e.g; ovarian cysts, endometriosis, fibroids, infertility,disorders of the cervix, menstrual disorders, penile/testiculardisorders, epididymitis, breast lumps/cysts, complications ofpregnancy/childbirth.
9 Gastro-intestinal disorders e.g. peptic ulcer, hiatus hernia, heartburn, changed bowelhabits, rectal bleeding, Crohn’s disease, ulcerative colitis,IBS (irritable bowel syndrome).
10 Immune system disorders e.g. HIV/AIDS, Addison disease, Graves disease, Multiplesclerosis, scleroderma, vasculitis.
11 Kidney/Urinary tract disorders e.g. kidney failure, kidney stones, recurrent infections,nephritis, prostate problems, blood/protein in urine, polycystickidneys.
12 Liver/Pancreatic disorders e.g. hepatitis, cirrhosis, liver failure, gallstones, pancreatitis.
13 Mental health/Psychiatric disorders e.g. depression, anxiety, schizophrenia, eating disorders,ADHD (attention deficit hyperactivity disorder), autism.
14 Metabolic/Endocrine disorders e.g. diabetes, thyroid abnormalities, growth disorder,Cushing’s disease, Addison’s disease.
15 Musculo-skeletal disorders (bone, joint, muscular) e.g. arthritis, rheumatoid arthritis, myasthenia gravis, muscleweakness/injury, gout, osteoporosis, back problems, (e.g.slipped disc, backache, sciatica, pinched nerve), loss of limb,breaks/fractures, sports injuries, hernia.
16 Respiratory disorders e.g. asthma, emphysema, bronchitis, shortness of breath,persistent cough,coughing up blood, cystic fibrosis, sinusitis,allergic rhinitis, COAD/COPD (chronic obstructiveairways/pulmonary disease) or any lung surgery.
17 Sensory functions e.g. loss or impairment of sense of touch, smell or taste.
18 Skin disorders e.g. eczema, psoriasis, acne, hypertrophic scars (keloid).

Note: You must declare any condition you have or had in your lifetime which may or may not have an impact on your future health. If you are in doubt as to whether a condition may be relevant to this application, you must declare it in good faith.

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Additional information - if you require more space, please continue upload a PDF file below.

1. Diagnosis/symptom (as ticked above)
2. Description of medication/treatment/investigations (PLEASE INCLUDE ALL DATES)
3. Do you require further consultations/treatment/investigations?
4. Present state of health (e.g. Full recovery or symptoms still present)

Download sample template
A PDF document stating more details on the pre-existing conditions selected above (Max file size: 2MB)
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General Notes

By submitting this application you confirm your understanding of the following:

1. Your cover will not start until we have accepted your application. Policy starts only after underwriting is completed (within 2 weeks), premium paid is a deposit payment until then.

2. Before we can assess your application, we may need to get a medical report from a GP or Physician or Surgeon who has cared for you.

3. That no cover will apply for investigations or treatment of any medical condition or related condition which exists or has existed before your cover start date unless, where requested within this application form, you have provided AXA Mansard Health Ltd with full details and we have agreed to accept it. You also understand that AXA Mansard Health Ltd will detail on your policy document/certificate of insurance any personal medical exclusion(s) that we’ve applied due to the information you have provided. You understand that in certain circumstances AXA Mansard Health Ltd may be unable to offer cover.

4. That the information given on this application form must be full and accurate. That failure to take reasonable care in answering any questions may result in a claim not being paid, your underwriting terms being changed, your cover being cancelled, and / or any treatment costs already paid by us being reclaimed.

5. That you give permission for the medical information you’ve provided to be disclosed to any employee in the AXA Mansard Health Ltd for risk management and underwriting purposes. This information can also be used to maintain management information for business analysis.

Declarations

I, the Life Assured, do hereby declare that all the foregoing answers are true, that I have not concealed nor withheld anything with which the assurer should be acquainted with in order to assess my eligibility for health insurance.
I agree that these and all statements I have made or shall make to the assurer or to its medical examiner(s) in connection with this or previous proposal(s) shall be the basis of this contract.
By signing this form, I authorize AXA Mansard Health Ltd to:

1. Request any provider to give AXA Mansard Health Ltd all health information about me, which may include: Treatment plans, dates of services, nature of accident or sickness, record of surgery, lab test results, including HIV.

2.Use health information to verify the information relevant to this application.


I agree that my personal information can be used in line with AXA Mansard’s Data Privacy Policy

AXA Mansard is joining the rest of the world in being environmentally responsible. We invite you to join us in this cause by using only the electronic copy of your policy document which will be sent to your registered email address. You can also access it from your online account at www.axamansard.com or on MyAXA Plus App (available on Play Store or IOS Store).

Should you still want to receive a hard copy of your document in addition to the electronic copy, please place a request with your account officer or send an email to insure@axamansard.com. Your choice to decline making such request will serve to indicate that you do not agree to partner with us to preserve the environment.

By clicking Submit you agree have agreed to the terms and condition stated above.

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