Prudential Assurance Uganda Limited 9th Floor, Zebra Plaza, Plot 23 Kampala Road P.O. Box 2660, Kampala, Uganda Tel: +256414343897/909, Email infos prudential.ue, www prudential Membership Application Form. E 1 VANT SECTION: PLET! E 1. Member's details SURNAME: [ JOTHER NAMES: ( PASSOHT NOT [mec a end) OE eT (| ‘OSTAL ADDRESS: [ ) NAME OF EMPLOYER: ( ) EMAIL ADDRESS [ ) 2. Dependants ¢o be covered. TELEPHONE: HOMI Particulars of family members joining (if the scheme covers s your dependents) Ts | NAME DATE OF BIRTH SEX(M7 FY RELATIONSHIP] BLOOD GROUP — Particulars of next of kin NAME ae eer ee Tea PES Geom = POSTAL ADDRESS EMAIL TEL. (MOBILE)L 7) Home Jorricey )© ONSIDLNTLAL ITEAL CH QUESTIONS AIG HAVE YOU OR ANY OF YOUR DEPENDANTS EVER HAD (BEEN DIAGNOSED AN! CONDITIONS? KINDLY ANSWER; YES/NO TO ALL 1 DOCTOR FOR ASSISTANCE IF NEEDED). NOTE: IF-THE ANSWER IS VES TO ANY OF THE QUESTIONS, YOU WILL ER PAUL MAY REQUEST YOU. HE QUESTION LOW. WOR TREATED FOR) ANY OF THE FOLLOWING MEDICAL ANSWERS ARE REQUIRED FOR BACH APPLICANT. (ASIC {EQUIRED TO PROVIL IDE DETAILS OF THE MEDICAL. CONDITION. ‘TO PROVIDE MEDICAL, REPORT, WITHOUT WHICH YOUR APPLICATION MAY UE DELAVES | herby declare tat tthe best of my knowledge and belie the inforsatins ven inthe application is true and complete. {agree tha the “shsions and esicions of te Scere willbe Binding on mead al eligible Sopantane eeccin a membership. Signature ' reinsert zs juz, Please attach a photocopy of your valid National Identification Gard / 0-3 months, copies of birth certificates for biological children aged 4 EMPLOYER SIGNATURE AND STAMP: ‘months and above. MEDICAL CONDITION nga [ Not Ned [ Nod [Not ities ere sates ge Sal Caner, grows ort wie Dain a maT Wa ee Carioca (hen and bod veel) dodo aedg Tigh ool Hema {] Ser Dep venous trombess consents heat ducas chen areas sy 34) deal emi hen de valet enemies eases, | yw vm Lym | ym | vaw | vy cory sy sein, peipera aria diewesheoma te tena eve and ay Respatoryand Eu Nove and Tor (ENT dios nog tube, hearing serch impaten,adomids deh in te oni now 34 ines note bcding. snus problem cguete swing, one ate ym [ym ym |v | vas | vn 2 eta ere an ORT Gabe, a aoa ey} NPAT VR tet Ha sonmena inbaieth dae ona sid oe 79] mesa rb ghoons Sienna TS MERTON Ta] VT nT —H La plas usr gery ein esae a ‘asin dsl ncn Fp Tes Uo a BSR 34 erent pat lech, gitar Seourhoatinterees (ym [vm |ym [ym Twn [wm aval srs etl edn endoeapy,clnoseny emotion a he Gjoeslogie & erie dada einngcaan eto Toot 5. cya infer, penta duce neared econ mo tym tym [vm [ym [vn fom sei homme etn mikey ears, upeseone ey ey Sil Treat ores pected dar oP acto SZ Gennaro cling ergs psi, ney re Gahan 29 ate deers pyemner ophin gonorte, clams getltemsomnd” |v vm Tym bem lum Tym ae a a lens, poring nutes, oneness nolan nooo Naroogal& preloaded pep eas TS DIE ‘chzaprns,deeson, ipl doce, pai atece pool aes ea 2 ett dtr onset mye me | vy | vy | am [am vm nerobulin, aller ru dependency Aion sa ay oe a cna Sores nlig kei FIVAIDS, alc —T RTT TR LH ceythematouss and any ther a oe a on byperophie su, area an the vn [vm [vm [vm [xm [var Tis any cls lave (excnding Tea] ST TRGNORT WF SP 3.12] deus high sbolserl, dubers grads sheneetie ee yn [vm [vm [ym [vm ] vas Fanswered YES tay athe qeston above ene nen SSCS No. | APPLICANT DATE CONDITION | TREATMENT | CONSULTING DOCTOR Ue a a ene tenes ov ion ghee pved wiv aim No pam reed Passport for all Adults, discharge report for babies