AXA MANSARD HEALTH CORPORATE PROPOSAL FORM

“AN INDIVIDUAL WHO ASSISTS AN APPLICANT TO COMPLETE

THIS PROPOSAL FORM FOR INSURANCE SHALL BE DEEMED TO
Main Member Passport HAVE DONE SO AS THE AGENT OF THE APPLICANT”

NATIONAL OILWELL VARCO

Company Name ____________________________________________ 4014405
Staff ID/Number ________________________
ORIAIFO, ISIMEMEN FRANK
Enrollee name (Surname, Other names) ___________________________________________________________________________
30/03/1990
Birth Date (DD/MM/YYYY) _______________________ NONE
Religion: _______________________ MARRIED
Marital Status: _________________ MALE
Sex: ___________________
REGIONAL SUPPORT ENGINEER, ESSA
Job Title: _________________________________________________ +2348188174748
Mobile No: _____________________________________________________________
PLOT 2, ELTINA CLOSE, OFF JC STREET, OFF PETER ODILI ROAD, PORT HARCOURT, RIVERS STATE
Address: ______________________________________________________________________________________________________________________________
ISIMEMEN.ORIAIFO@NOV.COM
Email: _______________________________________________________________Health Plan type: __________________Genotype& Blood Group____________
PARAGON CLINICS AND IMAGING
Choice of Hospital (Primary) ________________________________________________________________________________________________________________

Alternate Hospital (Secondary) _______________________________________________________________________________________________________________

NONE
State any Pre-Existing Medical Condition (Diabetes, hypertension, Sickle cell, Cancer, Kidney Issue, others…_______________________________

Dependents Details

SPOUSE CHILD 1

Full Name ________________________________________________ Full Name ________________________________________________________

Birth Date (DD/MM/YYYY) _______________________Sex________ Birth Date (DD/MM/YYYY) _____________________________ Sex_______

Primary Hospital __________________________________________ Primary Hospital __________________________________________

Secondary Hospital ________________________________________ Secondary Hospital _______________________________________

Pre-existing Condition ______________________________________ Pre-existing conditions _____________________________________

Occupation ______________________________________________ Telephone No _____________________________________________

Telephone No _____________________________________________

CHILD 2 CHILD 3
NATHAN AYOMIDE ORIAIFO
Full Name _________________________________________________ Full Name ________________________________________________________
02/09/2023 MALE
Birth Date (DD/MM/YYYY) _______________________Sex________ Birth Date (DD/MM/YYYY) _____________________________ Sex________
TEHILAH CHILDREN HOSPITAL
Primary Hospital __________________________________________ Primary Hospital __________________________________________
TBD
Secondary Hospital ________________________________________ Secondary Hospital ________________________________________
NONE
Pre-existing Condition ______________________________________ Pre-existing conditions _____________________________________
+2348188174748
Telephone No _____________________________________________ Telephone No _____________________________________________

CHILD 4

Full Name _________________________________________________ DECLARATION

Birth Date (DD/MM/YYYY) _______________________Sex________ ISIMEMEN ORIAIFO the assured, do hereby declare that all the foregoing answers
I,……………………………….
are true, that I have not concealed nor withheld anything with which the assurer should be
Primary Hospital __________________________________________ acquainted with in order to assess my eligibility for health insurance.

Secondary Hospital ________________________________________ Are there any additional facts affecting the risk of assurance on your health of which the
company should be made aware?
Pre-existing Condition ______________________________________ Yes ____ No_____
NO If Yes, enter the details:……………………………………

Telephone No _____________________________________________
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.
07 / NOV / 2023
Client Signature ____________________________________ Date ________________________________

NOTE: kindly affix recent photographs, following sequence as stated.