ICEA GENERAL INSURANCE COMPANY LIMITED

1st Floor, Rwenzori Courts, Nakasero

P. O. Box 37834, Kampala.
Tel 0414-250719/ 0794232337
0794232338/0708384329
E-mail iceamedical@icea.co.ug

MEDICAL INSURANCEAPPLICATION FORM

PLEASE READ THE FOLLOWING TERMS AND CONDITIONS

BEFORE YOU BEGIN COMPLETING THIS FORM

1. Fill this form in BLOCK letters and tick in the appropriate boxes
2. Fields with asterisks (*)are mandatory and must be completed by the applicant.
3. This form must be signed, dated and stamped the at the end.
4. Non-compliance to the terms and conditions may delay your enrolment into the medical scheme.
5. The information you provide on this application form will be treated with utmost confidentiality.
6. Please attach a copy of the Identification (National ID or Passport).

1. PRINCIPLE APPLICANT’S DETAILS

*Title (Please tick appropriate box) MR. MRS. MISS DR. PROF. REV. HAJJI
*First Name
*Surname
Other Names
*Occupation
*Date Of Birth
*Mobile No. Telephone No.
E-Mail Address
* Physical Address District

2. DEPENDANTS TO BE INSURED*
NAMES RELATIONSHIP BIRTH DATE CONTACT
1.
2.
3.
4.
5.

3. NEXT OF KIN*
Name
Relationship Tel. contact

4. MEDICAL HISTORY*
PLEASE NOTE: No liability will be accepted for any medical condition that originated or occurred before
the date of enrolment unless such medical condition has been declared to, and accepted by the Company.
Failure to notify the Company of a medical condition may result in claims of benefits being refused. If you
are in any doubt, you should disclose your medical condition. Please read and fill the questionnaire below;

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 a) Do you or any of your dependents included in this application have any disability, defect, chronic illness
congenital illness, eye conditions, heart conditions, Cancer or Tumors, Diabetes, Metabolic conditions like
Ulcers, Mental/psychiatry or any medical condition not mentioned that in good faith you may disclose?
YES NO
Name of Patient Pre-existing (current) Date Attending
condition/ disease Diagnosed Hospital/clinic
1.
2.
Has any of the above patients been admitted before for the condition above?
YES NO (attach a copy of discharge form & treatment Notes)

b) Have you or any of your dependents included in this application ever undergone a surgical procedure?
YES NO (Please attach discharge form)
Name of patient Operated Operation/ procedure(s) Date Attending
done of discharge Hospital/clinic
1.
2.

c) Are you or any of your dependents included in this application scheduled for surgery in the next Twelve
(12) months? YES NO
Operation/
Name of patient to be Scheduled Date of Attending
procedure(s) to be
Operated operation/procedure Hospital/clinic
done
1.
2.

d) Have you or any of your dependents included in this application been involved in an accident involving
hospitalization? YES NO
Nature of the Accident/ Date Attending
Name of patient
procedure of Discharge Hospital/clinic
1.
2.

e) Are you or any of your dependents included in this application pregnant or has a gynecological/
obstetrical condition; Fibroids, complications of pregnancy or any gynecological condition not mentioned
that in good faith you may disclose? YES NO
Gynecological/ Current/scheduled Date of treatment/
Name
Obstetrical Condition treatment/Procedure Delivery
1.
2.

5. APPLICANT DECLARATION*

I declare that the statements on this application form are full, true and correct and that I have read the
terms and conditions and agree to be bound by them and that the acceptance of my application shall
be upon the basis of these statements.

Signature________________________________________________Date__________________________

6. FOR CLIENT OFFICIAL MANAGEMENT USE ONLY:

Verification Officer______________________________________________________________________

Position_______________________________________________________________________________

Signature and Stamp_______________________________________ Date_________________________

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