MEDICAL POLICY

APPLICATION FORM

JUBILEE HEALTH INSURANCE COMPANY OF TANZANIA LIMITED

DIRECTIONS:
Head Office
1. Please answer all questions in BLOCK letters.
5th Floor, Amani Place ,Ohio Street
2. Please attach a passport--size photograph of yourself and of
P.O BOX 20524, Dar es Salaam
each member of your family proposed for insurance.
Tel: +255 22 2110176/80
Call Centre: 0746 811313
Email: enquiry@jubileetanzania.com
www.jubileetanzania.co.tz

SECYTION A: YOUR PERSONAL DETAILS

(a) Name of your employer:

(b) Member’s Surname: Other Names:

(c) Date of Birth:

(d) ID or Passport No.:

(e) Occupation: If more than one, state all

(f) Postal Address:

(g) Physical location of place of work: Building/Street

(h) Physical Home Address: Residence/Area/House No.

(i) Telephone - Office: House: Mobile:

(j) Personal Email:

SECTION B: SCHEDULE
To be completed if member’s family is covered for Medical Insurance.

NAMES IN FULL DATE OF ID CARD NO. / BIRTH RELATIONSHIP TO

BIRTH CERTIFICATE NO. / MEMBER
BIRTH NOTIFICATION
NO.

SECTION C: CONFIDENTIAL MEDICAL HISTORY

Please ensure that you have fully disclosed any known or suspected conditions and symptoms experienced by anybody included in this
application. In completing the questions please make sure you answer each question fully and accurately. Failure to disclose material
facts could affect payment of claims.

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(a) Do you or any member of your family proposed for this insurance already hold Life, Personal Accident or Medical Insurance
policies? Yes No
If Yes, please state name of insurers and policy numbers

(b) Have you or any member of your family proposed for this insurance had medical and surgical or other form of health treatment
during the past three years? Yes No

(c)
Have you or any member of your family proposed for this insurance suffered at any time from or become aware of any tendency
to infection of the chest, heart, spine, glands, bones or joints, digestive organs, kidneys, bladder or other organs?
Yes No

(d) Have you or any member of your family proposed for this insurance suffered at any time from rheumatism, diabetes, gastric
or duodenal ulceration, paralysis, gout, asthma, blood spitting, hernia, rheumatic fever, tuberculosis or from any nervous
disease? Yes No

(e) Have you or any member of your family proposed for this insurance suffered from any complaint which may necessitate a
surgical operation or for which you reasonably anticipate the necessity of treatment? Yes No

(f) Have you or any member of your family proposed for this insurance suffered from chronic/long term medical, optical or dental
condition or is there any other known disability, abnormality or recurrent illness or injury? Yes No

(g) Have any of your immediate relatives (child, father, mother, sister or brother) suffered from rheumatism, gout, kidney related
problem, high blood pressure, cancer, diabetes, heart disease, asthma, epilepsy, blood disorder or any chronic illness?
Yes No

(h) Are you or any member of your family proposed for insurance now under observation or taking treatment or medication for
any disease or disorder? Yes No

(i) Do you or any member of your family proposed for insurance currently pursue or intend to pursue any profession, occupation,
sport or hobby which is hazardous? Yes No

Please state the name and address of your medical doctor/physician or hospital

Note: If the answer is YES to any question above please provide full details below.

NAME AND RELEVANT MEDICAL TREATMENT AND NAME OF THE NEEDS FOR
RELATIONSHIP TO THE QUESTION CONDITION CONSULTATIONS TREATING DOCTOR FUTURE
APPLICANT RECEIVED (WITH DATE) OR HOSPITAL AND TREATMENT OR
TEHIR TELEPHONE CONSULTATION
NUMBER OR
ADDRESS

SECTION D: DECLARATION OF MAIN MEMBER

I, on behalf of myself and the members of my family proposed for insurance, hereby declare that I have not withheld or misstated any
particular material fact. I understand that any misstatement or non disclosure of any material information in this form will jeopardize
my membership.I hereby authorise the hospitals/medical practitioners who have treated me or any of my dependants to disclose to
Jubilee Health Insurance Limited or their representative the records relating to such current or previous hospitalisation/medical treatment
and allow Jubilee Health Insurance Limited to receive extracts from such records and undertake to assist in obtaining such information.

Signature of Member___________________________________________Date__________________________________

Signature/Stamp of Employer___________________________________Date__________________________________ PAGE 2