MEDICAL INSURANCE
GROUP MEMBERSHIP APPLICATION
JUBILEE HEALTH INSURANCE LIMITED
Head Office: DIRECTIONS:
Jubilee Insurance House, Wabera Street,
P.O. Box 6694 - 00100 GPO, Nairobi, Kenya Please answer all questions in BLOCK letters.
Tel: +254 20 328 1000
Call Centre: +254 709 949 000 • Please attach a passport size colour photograph
Email: talk2us@jubileekenya.com of yourself and each member of your family
www.jubileeinsurance.com proposed for insurance on the photo sheet page
provided.
• Kindly complete all questions in full. Incomplete
application forms cannot be processed.
YOUR PERSONAL DETAILS
(a) Name of your employer
(b) Title Member’s First Name
(c) Member’s surname Other names
D D M M Y Y
(d) Date of birth / / Blood Group
(e) ID or passport number Gender: Male Female
(f) Occupation If more than one, state all
(g) Postal address
(h) Physical location of place of work Building/Street
(i) Physical home address Residence/Area/House No.
(j) Telephone - Office Personal Mobile
(k) Personal Email
SCHEDULE
To be completed if member’s family is covered for Medical Insurance
Date of birth Identity card no. /
Names in full Blood Relationship
(day/month/year) Birth certificate no. /
Group to member
Birth notification no.
1.
2.
3.
4.
5.
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.
(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
Consultations given and Name of the treating doctor Needs for future
Name and relationship Relevant Medical condition treatments received or hospital and their treatment or
to the applicant question (with date) telephone number or address consultation
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_____________________________________
