Singapore Medical Insurance Underwriting Question

1. Is any Life to be Insured currently insured under or applying for any medical, hospitalisation, accident or life insurance?
YES | NO

2. Has any application for medical, hospitalisation, accident or life insurance on any Life to be Insured ever been declined, postponed or accepted at other than normal terms by Great Eastern Life (the Company) or any other insurance company(ies)?
YES | NO

3. Has any Life to be Insured ever made a claim against our Company or any other insurance company(ies) in respect of any medical, hospitalisation, accident or life insurance?
YES | NO

4. PLEASE COMPLETE THIS SECTION CAREFULLY.
Have you/or any of the Life to be Insured ever had or been told or been treated for:
(a) eye, ear, nose or throat problems e.g. ear discharge, cataract, glaucoma, hearing, nasal bleeding or speech impairment, etc?
YES | NO

(b) chest or breathing complaint(s) e.g. asthma, bloodspitting, persistent cough, pleurisy, bronchitis, tuberculosis or other respiratory problem?
YES | NO

(c) heart problem or chest pain e.g. rheumatic fever, palpitation, raised blood pressure, low blood pressure, angina, murmur, heart attack, etc?
YES | NO

(d) blood disorder or been refused as a blood donor?
YES | NO

(e) complaint(s) of the digestive system, liver (including hepatitis or hepatitis carrier status), jaundice, ulcer, hernia, chronic indigestion, gallbladder, intestines, stomach, bowel or rectal bleeding, bladder or urinary disorder, endocrine disease, diabetes or thyroid problem?
YES | NO

(f) albumin, blood, pus or sugar in urine, renal stones or any other disorders of the kidney, bladder or genital organs?
YES | NO

(g) brain disorder or problem(s) affecting the nervous system including epilepsy, paralysis, numbness, dizziness, prolonged headache, loss of balance or fits?
YES | NO

(h) cancer or tumour, cyst, lump or other growths of any kind?
YES | NO

i. pain or other problems in the back, spine, muscles or joint, arthritis, gout, severe injury or other physical disability?
YES | NO

(j) alcoholism, drug abuse, depression, psychological or mental disorder?
YES | NO

(k) sexually transmitted disease such as gonorrhoea, syphilis, non-specific urethritis, any other venereal disease, AIDS or AIDS related condition or infection with any Human
Immunodeficiency Virus (HIV)?
YES | NO

(l) gynaecological disorders such as endometrosis, ovarian growth, fibroid, irregular menstrual bleeding, abnormal pap smear results, etc?
YES | NO

(m) congenital anomalies and physical defects?
YES | NO

(n) ever been recommended/advised to undergo any special investigations, eg. mammogram, colonscopy, coronary angiogram, etc?
YES | NO

(o) sought medical advice, been investigated, been diagnosed, been hospitalized, received medical treatment, undergone surgical operation, or been prescribed drugs at anytime OTHER THAN
i) Cold or influenza lasting for less than 7 days
ii) Sprains or strains that healed within 14 days
iii) Food poisoning or diarrhoea lasting for less than 2 days
iv) Minor cuts and abrasions which did not require medical attention for more than 7 days.
YES | NO

(p) been aware of the existence of any signs and symptoms in the last 12 months which would require counselling, undergoing of investigation or diagnostic tests, hospitalisation, receiving medical treatment, undergoing surgical operation or prescription of drugs?
YES | NO

5. What is the name and address of your personal or family doctor (if any)?

6. Has any Life to be Insured ever smoked in the last 12 months? If "Yes", please state Name of Life to be Insured and average daily consumption.
YES | NO

7. Are there any risks, special dangers or conditions which may be considered hazardous connected with any Life to be Insured's job, hobbies or past-time activities? If "Yes", please give details.
YES | NO

8. Does the Proposer have other children who are not insured? If yes, please state the reason(s)
YES | NO

9. Has any Life to be Insured any intention of residing outside Singapore for a period of 90 days or more in the near future? If "Yes", please complete and submit Declaration PHP-OVS form (Supplementary Declaration: Residence Overseas) manually. (If a Life to be Insured has resided overseas for more than 90 days when receiving treatment, then any Eligible Expenses for such Treatment shall be limited to the Reasonable and Customary charges for such treatment in the Republic of Singapore.)
YES | NO

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