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C & C Insurance Consultants


AIG Health Insurance for Expatriates

Please read the policy before filling out the application.


STEP 1: TRAVEL AND TRIP INFORMATION

What is your birth date?   (yyyy-mm-dd)
Effective Date of this policy (yyyy-mm-dd)
Termination Date of this policy (yyyy-mm-dd)
OR Duration of coverage days
Coverage details:    
Country of origin:  
Destination Country:  
Do you wish to apply for Family or Single Coverage?
Family Single
Note: Family denotes two adults plus dependants named in the Notes section.

STEP 2: UNDERWRITING OPTION - choose one of the options from the following menu:

 
I declare that I do not want coverage for any pre-existing conditions.
I will complete the medical questionnaire.
TAKE A RISK
COVER MY CONDITION(S)

 

STEP 3: MEDICAL QUESTIONNAIRE - your answers form the medical statement and become part of the policy. The onus is on you to tell the insurer everything that has affected your health status.You must click Yes for any condition that you had symptoms, been investigated for, received consultation or Treatment for, or had a change in medication or a change in Treatment for, been Hospitalized for or been diagnosed with.
  1. Check whether the stability clause is based on the Effective Date or the Application Date.
  2. If you have been prescribed medicine or a course of care by a doctor or have sought care from a licensed practitioner, you will be considered to have received treatment for a medical condition or injury.
  3. Certain underwriting rules may exclude a condition or reject the application.
  4. The policy is void if there is a material mistake in the medical statement.

Medical Conditions

Current Medications

The medical condition has been Stable for

 
CARDIOVASCULAR:
Have you ever been prescribed or taken medication, or diagnosed with or had an investigation, medical consultation or treatment for the following conditions? Medications  Stability before the Effective Date"Stable and Controlled" means a medical condition for which:
  1. there has been NO increase in symptoms or development of new symptoms; NO test results showing deterioration,
  2. a Physician has not determined that the condition has become worse,
  3. a Physician has NOT recommended or prescribed a reduction, increase or stoppage in medication dosage or its frequency, or a change in Treatment,
  4. a Physician has NOT recommended or prescribed a new medication,
  5. You have NOT been Hospitalized or required medical consultation (other than a routine examination where NO medical signs or symptoms existed or were found during the exam), and
  6. You are NOT awaiting further investigation, or results thereof, for that medical condition.
 
 
Arrhythmia
Yes No
 
Atrial fibrillation
Yes No
 
Heart murmur
Yes No
 
Chest pain/Angina
Yes No
 
Myocardial infarction (Heart attack)
Yes No
 
Arteriosclerosis/Angioplasty
Yes No
 
Congestive heart failure
Yes No
 
Arterial by-pass within last 8 years
Yes No
 
Arterial by-pass over 8 years ago
Yes No
 
Aneurysm
Yes No
 
Other cardiac problems
Yes No
 
Description of the other heart/cardiovascular problems
Yes No
 
CEREBROVASCULAR OR NEUROLOGICAL:
Have you ever been prescribed or taken medication, or diagnosed with or had an investigation, medical consultation or treatment for the following conditions? Medications  Stability before the Effective Date"Stable and Controlled" means a medical condition for which:
  1. there has been NO increase in symptoms or development of new symptoms; NO test results showing deterioration,
  2. a Physician has not determined that the condition has become worse,
  3. a Physician has NOT recommended or prescribed a reduction, increase or stoppage in medication dosage or its frequency, or a change in Treatment,
  4. a Physician has NOT recommended or prescribed a new medication,
  5. You have NOT been Hospitalized or required medical consultation (other than a routine examination where NO medical signs or symptoms existed or were found during the exam), and
  6. You are NOT awaiting further investigation, or results thereof, for that medical condition.
 
 
Cerebrovascular accident
Yes No
 
Transient ischemic attack
Yes No
 
Neurological disorder (Alzheimer's, Parkinson's, Syncope )
Yes No
 
Other cerebrovascular or neurological conditions or disorders
Yes No
 
Description of the other cerebrovascular or neurological conditions
Yes No
 
RESPIRATORY:
Have you been prescribed or taken medication, or diagnosed with or had an investigation, medical consultation or treatment in the last 5 years for the following conditions? Medications  Stability before the Effective Date"Stable and Controlled" means a medical condition for which:
  1. there has been NO increase in symptoms or development of new symptoms; NO test results showing deterioration,
  2. a Physician has not determined that the condition has become worse,
  3. a Physician has NOT recommended or prescribed a reduction, increase or stoppage in medication dosage or its frequency, or a change in Treatment,
  4. a Physician has NOT recommended or prescribed a new medication,
  5. You have NOT been Hospitalized or required medical consultation (other than a routine examination where NO medical signs or symptoms existed or were found during the exam), and
  6. You are NOT awaiting further investigation, or results thereof, for that medical condition.
 
 
COPD
Yes No
 
Asthmatic bronchitis/Bronchial asthma
Yes No
 
Chronic bronchitis
Yes No
 
Emphysema
Yes No
 
Home Oxygen
Yes No
 
Oral Cortisone Tablet
Yes No
 
Other lung disorder or respiratory condition
Yes No
 
Description of the other respiratory conditions
Yes No
 
KIDNEY, GASTRO-INTESTINAL, DIGESTIVE OR LIVER:
Have you been prescribed or taken medication, or diagnosed with or had an investigation, medical consultation or treatment in the last 5 years for the following conditions? Medications  Stability before the Effective Date"Stable and Controlled" means a medical condition for which:
  1. there has been NO increase in symptoms or development of new symptoms; NO test results showing deterioration,
  2. a Physician has not determined that the condition has become worse,
  3. a Physician has NOT recommended or prescribed a reduction, increase or stoppage in medication dosage or its frequency, or a change in Treatment,
  4. a Physician has NOT recommended or prescribed a new medication,
  5. You have NOT been Hospitalized or required medical consultation (other than a routine examination where NO medical signs or symptoms existed or were found during the exam), and
  6. You are NOT awaiting further investigation, or results thereof, for that medical condition.
 
 
Peptic Ulcer
Yes No
 
Diverticulitis
Yes No
 
Intestinal bleeding
Yes No
 
Stomach/bowel disorder
Yes No
 
Liver disease
Yes No
 
Kidney disorder (dialysis not covered)
Yes No
 
Urinary disorder
Yes No
 
Spleen/Pancreas/Gall Bladder disorder
Yes No
 
Polyps
Yes No
 
Other Gastro-Intestinal/Liver condition
Yes No
 
Description of the other gastro-intestinal/liver conditions
Yes No
 
CANCER:
Have you ever been prescribed or taken medication, or diagnosed with or had an investigation, medical consultation or treatment for the following? Medications  Stability before the Effective Date"Stable and Controlled" means a medical condition for which:
  1. there has been NO increase in symptoms or development of new symptoms; NO test results showing deterioration,
  2. a Physician has not determined that the condition has become worse,
  3. a Physician has NOT recommended or prescribed a reduction, increase or stoppage in medication dosage or its frequency, or a change in Treatment,
  4. a Physician has NOT recommended or prescribed a new medication,
  5. You have NOT been Hospitalized or required medical consultation (other than a routine examination where NO medical signs or symptoms existed or were found during the exam), and
  6. You are NOT awaiting further investigation, or results thereof, for that medical condition.
 
 
Leukemia
Yes No
 
Cancer is eliminated
Yes No
 
Currently being treated with Radiation or Chemotherapy
Yes No
 
Currently active and not being treated
Yes No
N/A  N/A   
Currently being treated with Other
Yes No
 
 
DIABETES:
Have you been prescribed or taken medication, or diagnosed with or had an investigation, medical consultation or treatment in the last 5 years for the following? Medications  Stability before the Effective Date"Stable and Controlled" means a medical condition for which:
  1. there has been NO increase in symptoms or development of new symptoms; NO test results showing deterioration,
  2. a Physician has not determined that the condition has become worse,
  3. a Physician has NOT recommended or prescribed a reduction, increase or stoppage in medication dosage or its frequency, or a change in Treatment,
  4. a Physician has NOT recommended or prescribed a new medication,
  5. You have NOT been Hospitalized or required medical consultation (other than a routine examination where NO medical signs or symptoms existed or were found during the exam), and
  6. You are NOT awaiting further investigation, or results thereof, for that medical condition.
 
 
Diabetes with insulin
Yes No
 
Diabetes with medication (not insulin)
Yes No
 
Diabetes without medication
Yes No
 
Diabetes with weight loss recommended by doctor
Yes No
 
 
OTHER ELIGIBILITY OR RISK FACTORS:
Have you been prescribed or taken medication, or diagnosed with or had an investigation, medical consultation or treatment for the following? Medications  Stability before the Effective Date"Stable and Controlled" means a medical condition for which:
  1. there has been NO increase in symptoms or development of new symptoms; NO test results showing deterioration,
  2. a Physician has not determined that the condition has become worse,
  3. a Physician has NOT recommended or prescribed a reduction, increase or stoppage in medication dosage or its frequency, or a change in Treatment,
  4. a Physician has NOT recommended or prescribed a new medication,
  5. You have NOT been Hospitalized or required medical consultation (other than a routine examination where NO medical signs or symptoms existed or were found during the exam), and
  6. You are NOT awaiting further investigation, or results thereof, for that medical condition.
 
 
Circulatory disorder of artery or vein (Phlebitis, Thrombosis, PVD)
Yes No
 
Blood disorder (Anemia and other)
Yes No
 
Prostate disorder (not cancer)
Yes No
 
Arthritis
Yes No
 
Musculoskeletal disorder (not Arthritis)
Yes No
 
High blood pressure/Hypertension
Yes No
 
High cholesterol
Yes No
 
Other medical/physical disorder
Yes No
 
Description of the other medical/physical/musculoskeletal disorder
Yes No

Notes 
Please enter any additional, pertinent information and any other information relating to your health here: (500 characters)

I confirm that I have followed the instructions set out below:

  1. I have reviewed my answer to each question to ensure that I have answered each question truthfully, accurately and completely so that SRMRM can accurately calculate premium appropriate for my health status,

  2. I selected the number of medications that I am taking for each medical condition (be sure the total number of medications that you are taking is correct) and then

  3. I selected the period my medical condition has been Stable since the last occurrence of any new or change in symptom, investigation, consultation, new or change in medication, new or change in Treatment, or Hospitalization that I had for each condition.