RETAIL MEDICAL POLICY

MEDICAL INSURANCE
MEMBERSHIP APPLICATION FORM
INSURANCE

Head Office:
Jubilee Insurance House, Wabera Street,
P.O. Box 30376 - 00100 GPO, Nairobi, Kenya
DIRECTIONS:
Tel: +254 020 328 1000
PLEASE ANSWER ALL QUESTIONS IN BLOCK LETTERS.
Fax: +254 020 328 1150
Email: jic@jubileekenya.com
Please attach a copy of your PIN Card, ID/Passport, Birth
www.jubileeinsurance.com
certificate/ notification (for children below 18 years). You are
required to attach passport size colour photographs for each
Mombasa Office:
member on the photosheet page provided.
Jubilee Insurance Building, Moi Avenue,
P.O. Box 90220 - 80100, Mombasa, Kenya
Kindly complete all questions in full. Incomplete application forms
Tel: +254 020 222 4286 / 231 4019 / 231 6760
cannot be processed.
Fax: +254 020 231 6796
Email: mombasa@jubileekenya.com

Kisumu Office:
Jubilee Insurance House, Oginga Odinga Road,
P.O. Box 378 - 40100, Kisumu, Kenya
Tel: +254 020 202 0836 / 202 0845
Fax: +254 020 202 0532
Email: kisumu@jubileekenya.com

1. DETAILS OF MAIN APPLICANT

* All names should be captured as shown in ID/Passport and Birth Certificate for child dependants

Surname Title

First name Other names

ID or Passport No. Gender Male Female

PIN No. NHIF No.

Date of birth Marital

D DMMY Y Y Y Status

Height (ft) Weight (kg)

Name of employer (if applicable)

Occupation Nationality

CONTACT INFORMATION

Postal address

Physical home address

Home telephone Office telephone

Mobile phone Email

PARTICULARS OF NEXT OF KIN

Name in Full

Relationship ID or PP No.

Telephone No. Postal Address

PARTICULARS OF BENEFICIARY OF PERSONAL ACCIDENT COVER AND/ OR LAST EXPENSE COVER

Name in Full

Relationship ID or PP No.

Telephone No. Postal Address

2. DEPENDANT’S DETAILS
Please note children will be eligible for cover from the age of 1 month upto17 years.

Dependant 1
Surname Title

First name Other Names

ID or Passport No Gender Male Female

DOB
D D MM Y Y Y Y Marital Status

Height (ft) Weight (kg)

Relationship to Applicant Occupation

Dependant 2
Surname Title

First name Other Names

ID or Passport No Gender Male Female

DOB Height
D D MM Y Y Y Y (ft) Weight (kg)

Relationship to Applicant Occupation

Dependant 3
Surname Title

First name Other Names

ID or Passport No Gender Male Female

DOB Height
D D MM Y Y Y Y (ft) Weight (kg)

Relationship to Applicant Occupation

Dependant 4
Surname Title

First name Other Names

ID or Passport No Gender Male Female

DOB Height
D D MM Y Y Y Y (ft) Weight (kg)

Relationship to Applicant Occupation

Dependant 5

Surname Title

First name Other Names

ID or Passport No Gender Male Female

DOB Height
D D MM Y Y Y Y (ft) Weight (kg)

Relationship to Applicant Occupation

3. PLAN DETAILS

Inpatient is a core benefit. Dental and Optical options are available only with Outpatient plans.
Please tick (√) the plan chosen or required and the riders
Plan Limit (Kshs) Classic Premier Advanced Executive Royal
Inpatient 500,000 1,000,000 2,000,000 3,000,000 5,000,000
Outpatient 50,000 50,000 80,000 100,000 150,000
Maternity 80,000 100,000 120,000 120,000 150,000
Personal Accident 500,000 500,000 500,000 500,000 500,000
Optical 5,000 10,000 20,000 30,000 40,000
Dental 5,000 10,000 20,000 30,000 40,000
Last Expense 50,000 50,000 75,000 100,000 100,000

Premium Computation
Premiums (in Kshs)
Inpatient Outpatient Maternity Last ex- Personal Evacuation Dental & Totals
pense Accident Optical
Main Member
Spouse
Child I
Child II
Child III
Child IV
Child V
Total Premiums

Insurance Training
Levy (0.2%)

Policyholder
Compensation
Fund Levy (0.25%)

Stamp Duty 40.00

Total Amount

Commencement of cover will be subject to issuance of an acceptance letter and receipt of full premium by Jubilee
Insurance. All premiums must be paid to Jubilee Insurance directly. We shall not be liable for any premiums
made to other parties and not received by Jubilee Insurance.

4. DETAILS OF PREVIOUS MEMBERSHIP

Name of Scheme/Plan - Principal Applicant

________________________________________________________________ From: dd/mm/yy To: dd/mm/yy

Name of Scheme/plan – Spouse

________________________________________________________________ From: dd/mm/yy To: dd/mm/yy

Have you or any of your dependants ever been declined, loaded, or had exclusions applied on them by a medical
scheme? Yes/No
If ‘yes’ please provide details _________________________________________________________________________

__________________________________________________________________________________________________

Have you or any of your dependants lodged a claim in the last one year? Yes/No
If ‘yes’ please provide details _________________________________________________________________________
5. CONFIDENTIAL MEDICAL HISTORY

State whether you or any of your dependants have ever been treated or are currently receiving treatment, or expect to
receive treatment for any of the following illnesses including but not limited to:
Applicants are numbered as per section 2. Please indicate Yes or NO in the applicant’s box below. Note the main applicant is No. 1.
Question No. 1 No. 2 No. 3 No. 4 No. 5 No. 6
1. Blood disorders. e.g. anemia, bleeding disorders, leukemia

2. Cancer, growths or tumors whether benign or malignant

3. Cardiovascular (heart and blood vessels) disorders e.g. high blood pressure,
varicose veins, palpitations, deep vein thrombosis
4. Ear, nose and throat disorders e.g. hearing/speech impairment, ear infections,
sinus problems, nasal/throat surgery, tonsils, adenoids, previous nasal injuries,
upper airway infections, epistaxis
5. Endocrine disorders e.g. diabetes, high cholesterol , thyroid abnormalities
6. Eye related disorders e.g. blindness, glaucoma, eye surgery, , cataracts, lens
implants, refractive and laser surgery
7. Genito-urinary system e.g. Pelvic inflammatory disease prostate problem,
abnormalities of the penis, scrotum. Reproductive system, blood in the urine,
kidney stones, kidney failure, bladder problems, Dialysis,
8. Gastro-intestinal disorders e.g. recurrent indigestion, heartburn, ulcers, hernia,
piles, fissures.
Have you ever had any endoscopic study of the oesophagus, stomach or
colon?
9a. Gynecological and obstetrical disorders e.g. Fibroids, ectopic pregnancy,
caesarian section, Menstrual irregularities. Abnormal pap smear, receiving
hormone treatment. Uterine bleeding, Laparoscopic surgery, Dilatation and
curettage, miscarriages, pregnancy related problems.
9b. Pregnant, if positive, provide expected date of delivery (dd/mm/yy)
10. Musculo-skeletal disorders e.g. arthritis, Back problems, gout, osteoporosis. All
joint problems and fractures
11. Neurological disorders e.g. epilepsy, Stroke. Brain or spinal cord disorders,
Headache, migraine, Paralysis, meningitis
12. Psychological disorders e.g. alcohol or drug dependency, anxiety disorder,
insomnia, depression, stress, attention deficit disorder, post traumatic stress,
attempted suicide,
13. Respiratory disorders e.g. asthma, rhinitis, chronic bronchitis, cigarette smoking
related disorders, tuberculosis, persistent cough, allergies, chronic obstruction
pulmonary disease, shortness of breath.
14. Skin disorders e.g. eczema, melanoma, skin cancer, burns, scars, keloids,
warts
15. State whether you or any of your dependants have received medical advice or
treatment for any tropical disease e.g. leprosy, sleeping sickness, elephantiasis,
bilharzia, yellow fever
16. Have you or any of your dependants ever sought counseling or treatment in
connection with sexual transmitted infection e.g. gonorrhoea, syphilis, herpes
simplex, Chlamydia
17. Have you or any of your dependants ever sought counseling or treatment in
connection with HIV or AIDS infections or tested positive for HIV or AIDS?
18. Do you or any of your dependants have any hereditary disorders, birth defects
or congenital conditions?
19. Do you or any of your dependants have incomplete dental treatment plan,
dental implants, orthodontic treatment, dentures, and wisdom teeth problems or
do you or any of your dependants currently receive, or expect to receive dental
treatment in the next 12 months?
20. Investigations and/or specialized treatment: In and out of hospital
a) Are you or any of your dependants currently undergoing or expect to
undergo investigations for any medical condition and / or symptoms
not yet diagnosed?
b) Are you or any of your dependants currently receiving, or expect to
receive specialized treatment (i.e. chemotherapy, radiotherapy, bone
marrow transplant, mechanical ventilation, oxygen therapy, dialysis,
psychotherapy or counseling?
21. Are you or any of your dependants on any medication (please indicate in the
table provided below)
If you answered YES (number 21) please supply details below
Applicant Prescribed Medication Diagnosis Date Started/
To Be Started

If you answered YES to any of the questions above, please supply full details below
Q.NO. Applicant Date Diagnosis Treatment Consulting Physical address/
Doctor Telephone
Number

(If the space provided is insufficient, please attach additional information to this application.)

6. SURGERY AND HOSPITAL ADMISSIONS

Please supply details of all surgical procedure(s) and ALL HOSPITAL ADMISSIONS that you or any of your dependants
have undergone in the past, and /or details of all planned surgical procedure(s) and ALL HOSPITAL ADMISSIONS that
you or any of your dependants expect to undergo in the future?
Applicant Surgical Procedure/ Hospital Admission Date Diagnosis

(If the space provided is insufficient, please attach additional information to this application.)

N.B: Any misrepresentation or non-disclosure of material or factual information will render all benefits granted by
Jubilee Insurance null and void. In addition, any claims payment made due to such actions will be recoverable from
the policy holder.

7. GENERAL EXCLUSIONS
A. Expenses incurred as a result of a Member’s participation in:
1. Naval, military or air force service, paramilitary, police and police reserve service or operations;
2. Expenses arising directly or indirectly as a result of participation in and not limited to professional sport or any
especially hazardous pursuits such as motor cycling or motor racing machines of greater than 125 cc, polo, racing
on horse-back, rugby, league footfall, Winter sports, yachting, sky-diving, hang-gliding, parachute jumping, bungee
jumping, hunting, aqualung diving, boxing, wrestling or unarmed combat, water ski-jumping, mountaineering
necessitating the use of ropes or guides
3. Riding or driving in any kind of race;
4. Air travel except as a fare-paying passenger in any aircraft licensed for passenger carrying. Cover shall not in any
event apply to a Member whilst operating, learning to operate or serving as a Member of a crew of any aircraft or to
travel in any aircraft being used for sky-diving, racing, testing or exploration.
B. Expenses directly or indirectly incurred as a result of:
1. War invasion (“declared or undeclared”), riot, strike and civil commotion, act of foreign enemy, hostilities or warlike
operations, civil war, mutiny, insurrection, revolution, military or popular rising, military or usurped power, martial law
or state of siege or any events or causes which determine the proclamation or maintenance or martial law or state of
siege, confiscation, seizure, nationalization or destruction of or damage to the property by order of Government (de
jury or de facto) or Land Authority or any process of Law.
2. Medical expenses directly or indirectly resulting from or in connection with any act of terrorism (“declared or
undeclared’) regardless of any other cause contributing concurrently or in any other sequence to the medical
expenses.
3. Costs directly or indirectly resulting from the release of weapon(s) of mass destruction, whether such involves an
explosive sequence(s) or not.
4. Treatment directly or indirectly arising from or required as a result of chemical contamination or contamination by
radioactivity from any nuclear material whatsoever or from the combustion of nuclear fuel, asbestosis or any related
condition. Nuclear fission, ionising or non-ionising radiation or contamination by radioactivity from nuclear fuel or
waste. For the purpose of this exclusion, combustion shall include any self- sustained process of nuclear fission.
5. Intentional self-injury, suicide or attempted suicide (whether sane or insane) or any bodily injury or illness wilfully self-
inflicted or due to negligent or reckless behavior or as a result of result of committing or helping to commit a criminal
act, except in an attempt to save a human life.
6. Venereal disease or any other sexually transmitted diseases or any related condition or complications thereof except for
HIV/AIDS subject to the applicable waiting period
7. Treatment for dependency on or abuse of alcohol, drugs, any substance abuse or any other addictive conditions of any
kind and complications, injury or illness arising directly or indirectly from such abuse or addiction;
8. Vaccinations or any treatment undertaken or carried out as a preventative measure including complications thereof but
not limited to check-ups, scans of any nature or any other form of disease and illness prevention including but not limited
to preventative medications and supplements. Only the Kenya Expanded Program on Immunization (KEPI) is covered for
children below 1.5 years where the maternity benefit is purchased. This shall be covered within the Outpatient limit and
subject to the applicable waiting period of the maternity benefit.
9. Treatment by chiropractors, acupuncturists, herbalists and other alternative treatments. Stays and/or maintenance or
treatment received in health hydro’s, nature cure clinics, spas or similar establishments or private beds registered as
a nursing home attached to such establishments or a hospital where the hospital has effectively become the insured
person’s home or permanent abode or where admission is arranged wholly or partly for domestic reasons.
10. Pregnancy, childbirth, maternity benefits, abortion, miscarriage, ante-or-postnatal care, caesarean operation. This
exclusion does not apply where maternity cover option has been purchased subject to twelve months waiting period
(12) the benefit shall exclude any treatment and expenses related to surrogacy.
11. Foetal Surgery
12. Family planning and fertility treatment any form of assisted conception and complications e.g. costs of treatment related
to infertility and impotence, hormonal imbalance, hormone replacement therapy (HRT). Investigations, diagnostics and
treatment of impotence, sexual dysfunction or any consequence thereof, treatment for sterilization or fertilisation,
vasectomy or other sexually related conditions or gender reassignment and related consequence.
13. Costs of treatment for, related to, Peri-Menopause, Menopause, Andropause, ageing, puberty and pre-menstrual tension
syndrome.
14. Cosmetic or beauty treatment and/or surgery, obesity, removal of fat or other surplus tissue from any part of the
body, whether or not for medical or psychological purposes, and any associated treatment costs consequent of such
treatment. This shall include breast reduction or enlargement. The only exception is reconstructive surgery resulting from
an accident.
15. Treatment of, related to, or caused by weight loss/gain, obesity, eating disorders or weight problems of any kind. This
includes but is not limited to the treatment of conditions such as anorexia nervosa, bulimia, bariatric, and any treatment
required for any condition caused as a result of these conditions.
16. Normal eye tests, non-medical/natural degenerative eye defects, including but not limited to Myopia, Presbyopia and
Astigmatism and any corrective surgery for non- medical/natural degenerative sight defects, except where the benefit is
purchased.
17. Routine or restorative dental treatment, whether or not performed by a medical practitioner or dental practitioner or
specialist or an oral and maxillofacial surgeon, except where the benefit is purchased.
18. Hearing tests or cost of hearing aids. This shall include treatment for, or arising from, but not limited to deafness caused
by an illness, accident, congenital abnormality or ageing.
19. Massage and hydrotherapy
20. Pre-existing and chronic conditions subject to twelve months waiting period and full declaration on the application at
policy inception.
21. All expenses associated with HIV/AIDS and related conditions subject to twelve months waiting period and full
declaration on the application at policy inception.
22. Congenital illness and conditions related to genetic disorders, and/or chromosomal disorders and hereditary conditions
subject to twelve months waiting period and full declaration on the application at policy inception.
23. Cancer treatment subject to twenty four months waiting period and full declaration on the application at policy
inception.
24. Treatment of Haemorrhoids, Fibroids, Hernia, Adenoidectomy, Hysterectomy and Thyroidectomy subject to twelve
months waiting period.
25. Occupational /Speech Therapy. Treatment for speech disorders, including stammering, learning difficulties,
hyperactivity, attention deficit disorder, speech therapy and, developmental, social or behavioural problems unless
caused by an accident
26. Psychiatric illness, mental disorders and/or insanity expenses subject to twelve months waiting period. These conditions
that are excluded shall include but are not limited to treatment for conditions such as, conduct disorder, attention deficit
hyperactivity disorder, autism spectrum disorder, oppositional defiant disorder, antisocial behavior, obsessive-compulsive
disorder, attachment disorder, adjustments disorders, as well as all treatments that encourage positive social-emotional
relationships, such as communication therapies, floor time and family therapy.
27. Costs for any illness, diseases or injuries arising from ear or body piercing and tattooing
28. Pain management
29. Claims arising or related or associated with Epidemics/Pandemics or unknown diseases.
30. Any claim for expenses relating to any contingency arising whilst the Member is outside the territorial limits of Kenya,
but this limitation shall not apply to any Member temporarily abroad and requiring emergency treatment for an illness or
injury that occurs during the period of travel provided that such period does not exceed six weeks in any one trip. Travel
and accommodation costs are not covered.
31. Any claim for expenses related to an accident or illness which may have occurred prior to the effective date or illness
occurring within Thirty (30) days of the effective date or to any illness where it was within the knowledge of a Member
that he was suffering from it at the effective date.
32. Costs related to locating a replacement organ removal of a donor organ from the donor, removal of an organ from
you for the purposes of transplantation into another person, purchase of a donor organ or transportation, any resulting
complications and all associated administration costs. Eligible organ transplant is subject to twelve months waiting
period.
33. Cost of providing, maintaining or fitting an external prosthesis or appliance or other equipment, medical or otherwise
except for wheelchairs (inpatient) , walking frames and crutches following treatment resulting from an accident.
34. Medical aids including but not limited to glucometers, blood pressure machines, and oxygen concentrators.
35. Bodily injury or disease and/or illness arising out of non-adherence to medical advice given by a registered medical
practitioner. This shall include treatment required as a result of failure to seek or follow medical advice or travel against
medical advise
36. Evacuation or travel costs not specifically authorised in writing by Jubilee Insurance prior to travelling.
37. All expenses in respect of illness/conditions that were subject to waiting periods when the member and dependent
joined the policy and purchased the benefit.
38. Experimental treatment and drugs not scientifically recognised or not proven to be effective based on established
medical practice.
39. Charges recoverable under any Workmen’s Injury Benefits Act, Personal Accident policies or Government Health
Services Schemes of compensation including NHIF or any other medical plan.
8. DECLARATION
General
1. I, the undersigned member:
1.1. Hereby apply for myself and my dependants to be registered on The Jubilee Insurance Co of Kenya Ltd, Medical
policy and have read, understood and agree to abide by the Rules of the policy.
1.2. Warrant that the contents of this application and any other documents which may be required in support thereof
are true, correct and complete, should there be any change in the state of health or illness suffered by myself or any
of my dependants from the date of signing this application form and the date of acceptance of the risk or by the
insurer, notification of such change will be provided to the insurer in writing with full details of condition/ailment;
1.3. Understand that the statement and answers provided form the basis of the contracts and any breach of my warranty
or non disclosure of any information material to the assessment of this application shall render any contracts to
which this appliction relates null and void and all premiums paid shall be forfeited;
1.4. Understand and accept that no benefit will be payable by the policy unless they are satisfied as to the validity of
a claim and have received all requirements which they may deem necessary including the results of such medical
examinations and tests that they may require me or my dependants to undertake;
1.5. Acknowledge and accept that the insurer reserves the right to cancel membership of the policy if any due premium
is not paid on the due date; and
1.6. Undertake to inform the insurer within 30 days should the situation stated above change.

Authority
2. Accepting that I am curtailing my and my dependants’ right to privacy but in order to facilitate the assessment of
the risks and the consideration of any claim, I irrevocably authorize;
2.1. The Insurer to obtain from any person, whom I hereby so authorize and direct to give, any information which the
insurer deems necessary,
2.2. I further authorize and instruct the insurer and any hospital concerned to give away information relating to myself
and my dependants to the insurer for the purpose of ensuring that the members of the policy receive appropriate
and necessary medical services while reducing inappropriate care and wastage of medical resources,
2.3. I understand and accept that the above authorization constitutes a partial waiver of my and my dependants’ right
to privacy.
3 I declare that:
3.1. My dependants(s) is/are residing with me,
3.2. I am liable for his/her family care,
3.3. The dependant(s) is/are my immediate family (Must be a blood relative),
3.4. I undertake to repay the insurer any amount by which claims paid out exceed benefits covered.

Signature of Member Date

Signature of Spouse Date

9. POLICY ACCEPTANCE

Jubilee Insurance hereby confirms that upon receipt of full premium the following documents will be issued within 30
days. The policy holder should contact Jubilee Insurance if the same is not received. The documents that will make up
the policy membership pack will include a Welcome letter, photocards for each member, the provider panel and policy
document.

10. INTERMEDIARY DETAILS

Full name of Intermediary

Trading as Tel

PIN No. Email

Intermediary Declaration
I hereby declare that I explained the benefits of this application and that the applicant is aware of the membership terms
and conditions of Jubilee Insurance Company of Kenya Limited.

Signature of Intermediary Date

Unit Managers Name (where applicable)

BDM’s Name (where applicable)

PHOTO SHEET
Date:





MAIN MEMBER 1ST DEPENDANT
PHOTOGRAPH PHOTOGRAPH

MAIN MEMBER: DEPENDENT 1
NAME (As per ID/Passport): NAME (As per ID/Passport):
PIN No.: RELATIONSHIP:
DOB: DOB:
ID/PASSPORT No.: ID/PASSPORT No.:

2ND DEPENDANT 3RD DEPENDANT
PHOTOGRAPH PHOTOGRAPH






DEPENDENT 2 DEPENDENT 3
NAME (As per ID/Passport): NAME (As per ID/Passport):
RELATIONSHIP: RELATIONSHIP:
DOB: DOB:
ID/PASSPORT No.: ID/PASSPORT No.:





4TH DEPENDANT 5TH DEPENDANT
PHOTOGRAPH PHOTOGRAPH

DEPENDENT 4 DEPENDENT 5
NAME (As per ID/Passport): NAME (As per ID/Passport):
RELATIONSHIP: RELATIONSHIP:
DOB: DOB:
ID/PASSPORT No.: ID/PASSPORT No.:

OFFICIAL USE ONLY

11. POLICY COMMENCEMENT DATE

Commencement Date: Day________ Month___________ Year_________

Subject always to Declaration section of this application form, the commencement date of this Policy will be the date on
which this application is accepted in writing by us. Please note the commencement date can be no more than 30 days
from the date of completion of this application. Under no circumstances will Policies be backdated.
Note: Cover is conditional upon full payment of premium and acceptance of your application that is only confirmed
when an acceptance letter is issued to you.