RUGARE MEDICAL MEMBERSHIP APPLICATION FORM:

ELECTRONIC DATA: (F.C.A.) FOREIGN CURRENCY ACCOUNT (USD)

NB: Without your banking details, your claims will not be paid.

PLEASE ENTER BELOW DETAILS OF THE APPLICANT(PRINCIPAL MEMBER) AND ALL DEPENDANTS TO BE INCLUDED IN THIS APPLICATION FOR MEMBERSHIP

MEDICAL HISTORY ( To be completed for all applicants)

(Pre-existing conditions may be excluded from foreign travel emergency assistance)
Please read carefully and complete all the required information by placing a tick in the correct box. If the answer to any of the questions is “YES”, please provide details in the space provided below in respect of the member or dependants applicable. Failure to disclose material information or the provision of incorrect information can result in immediate cancellation of your membership and benefits.

Have you, your spouse or any of your dependents experienced or are presently experiencing any of the following?

NB: IF YOU OR YOUR FAMILY SUFFER FROM ANY CHRONIC ILLNESSES, ( ie, DIABETES, ASTHMA, E.T.C.) PLEASE COMPLETE THE CHRONIC REGISTRATION FORM IN ORDER TO RECEIVE SPECIAL CHRONIC DRUGS, SECTION 15 ABOVE MUST ALSO BE COMPLETED.

DECLARATION BY PRINCIPAL MEMBER - ON BEHALF OF HIMSELF AND ALL HIS DEPENDENTS:

I declare that any false information in this application form, or the non disclosure of any material information will render the membership entirely null and void.
1. As the Principal Member, I confirm that the information provided in this application form; concerning both myself and my dependents, is accurate and complete.
2. I understand that any condition, including related emergencies, for which I or my dependents have received medical advice or treatment prior to the date
of joining, is excluded from benefits under the scheme until the applicable waiting periods have been fully served.
3. I understand that I or any of my dependants may be required to obtain a medical report or undergo a medical examination to provide further information on any of the conditions declared above.
4. I authorize RUGARE MEDICAL to have unrestricted access to my medical records but require their confidentiality to be maintained.
5. I have completed the medical history for myself and all my dependants declared in this application.
6. I understand that RUGARE MEDICAL reserves the right to withhold benefits for conditions or emergencies that arise as a direct result of reckless, negligent, or intentionally endangering behavior or habits. This includes, but is not limited to, actions such as jumping from a moving vehicle, excessive smoking and the abuse of alcohol or other substances.
7. I acknowledge that it is my responsibility to familiarize myself and my dependants with all relevant rules, procedures, and requirements of RUGARE MEDICAL, and seek clarification where necessary.
8. I understand that RUGARE MEDICAL, reserves the right to amend its terms at any time and will provide members with reasonable notice of such changes.