MSL

M
RC.685658

MARINA MEDICAL SERVICES (HMO)

5 Abeo Street, Wstern Avenue, Surulere, Lagos. Tel: 01-7612320, 08027316271, 0812080791
LIMITED
E-mail: info@marinamedicalhmo.com Website: www.marinamedicalhmo.com

Application form for Managed Care / Health Insurance H

Please complete in block letters and include passport photograph of each beneficiary, return completed application forms
to MMSL (HMO).
COMPANY
NAME
PLAN TYPE
Employee No.
Marital Status
SECTION A - APPLICANT’S DETAILS
PRINCIPAL BENEFICIARY
SURNAME PASSPORT
FIRST NAME (PLS WRITE THE NAME AT THE
BACK OF THE PASSPORT)
LAST NAME

NATIONALITY

STATE

SEX M F DATE OF BIRTH DD MM YY

HOME OR OFFICE ADDRESS

MOBILE PHONE OR
OFFICE PHONE Marital Status Single Married
E-MAIL DDRESS

PREFERRED HOSPITAL
NEXT OF KIN

SURNAME

FIRST NAME

LAST NAME

HOME OR OFFICE ADDRESS

SPOUSE
PASSPORT
MOBILE PHONE OR
(PLS WRITE THE
SPOUSE DETAILS NAME AT THE BACK
OF THE PASSPORT)
SURNAME

FIRST NAME F
M

LAST NAME

SEX M F DATE OF BIRTH DD MM YY

PREFERRED HOSPITAL

CHILD 1 DETAILS

SURNAME CHILD 1
FIRST NAME PASSPORT F
M

(PLS WRITE THE NAME

LAST NAME
AT THE BACK OF THE
SEX M F DATE OF BIRTH DD MM YY PASSPORT)

PREFERRED HOSPITAL

CHILD 2 DETAILS

SURNAME CHILD 2
PASSPORT
FIRST NAME F
M
(PLS WRITE THE
LAST NAME NAME AT THE
BACK OF THE
SEX M F DATE OF BIRTH DD MM YY PASSPORT)

PREFERRED HOSPITAL

CHILD 3 DETAILS

SURNAME CHILD 3
PASSPORT
FIRST NAME F
M
(PLS WRITE THE NAME
LAST NAME AT THE BACK OF THE
PASSPORT)
SEX M F DATE OF BIRTH DD MM YY

PREFERRED HOSPITAL

CHILD 4 DETAILS
CHILD 4
SURNAME
PASSPORT
FIRST NAME F
M
(PLS WRITE THE NAME
LAST NAME AT THE BACK OF THE
PASSPORT)
SEX M F DATE OF BIRTH DD MM YY

PREFERRED HOSPITAL
 Pre-existing / chronic condition : This refer to a ny present medical condition that requires continuing treatment / care.
Please indicate [ ] the affected beneficiary (ies) in the box below.
Beneficiaries Diabete Asthma Hypertension surgery Sickle Peptic Allergies Others
s cell ulcer

Principal

Spouse

Child1

Child2

Child3

Child4

\SECTION D

Disclaimer:

For individual enrollees, preexisting chronic condition(s) shall not be covered for the first year of joining the scheme; any such
condition(s) that are not disclosed before joining the scheme but detected to have been pre-existing before commencement of the
scheme will not be covered.

Subscribers to the scheme should note that the scheme commences 2 weeks after submission of properly filled form(s) and full
payment of premium.

Declaration:

I, ______________________________________________, have carefully read and understood all the policy conditions and
exclusions. I hereby declare that information supplied on this application form is true and complete; it shall be for the basis of
contract between the insured person(s) and Marina Medical Services (HMO) Ltd.

Sign_______ _ Date _________ _

SECTION E

For official use only

______________________

Head, Client Services

Approved: (Y) (N)

If (N) why__________________________ Processed by __________________________