Membership Application Form

Personal Information Occupation

Category:
First Name		Last Name
Landline		Mobile
Email
D.O.B
Gender
Address:
No. of members covered:

(B) DETAILS OF MEMBERS:

FULL NAME	D.O.B	BLOOD GROUP	OCCUPATION

DECLARATION
I/We hereby declare that all the above statements and particulars which
I/we have read and checked are true Correct and Complete and contains
information to me/us affecting the proposed insurance and trust this
and any other statement made by me/us to VICTORIA HOSPITAL shall be THE BASIS OF AND INCORPORATION IN THE
CONTRACT BETWEEN ME/US AND THE COMPANY. I HAVE UNDERSTOOD THAT IN CASE
OF PARTIAL LOSS, IF SUM INSURED FALLS SHORT OF MARKET VALUE ON THE DATE
LOSS, I HAVE TO BEAR THE PROPORTION OF SUCH SHORT FALL TO THE MARKET
VALUE.
I/WE FURTHER AGREE TO ACCEPT THE SCHEMES TERMS AND CONDITIONS SET
FORTH IN THE COMPANY′S POLICY.
I/WE FURTHER AGREE TO ACCEPT MEMBERSHIP ON THE TERMS AND CONDITIONS SET
FORTH IN THE COMPANY′S POLICY
(If signing for a company indicates authority and state the name of the
Company/Agency).
IMPORTANT NOTICE
This Proposal will form the basis of a legally contract and absolute
truth and accuracy in answering the questions is essential. Before
signing the SPECIAL DECLARATION ensure that ALL questions are answered
correctly. Failure to comply may result in the cancellation of cover
and/or the reputation of any claim
We agree that if we would wish to terminate our membership that we should do so in writing and deliver it to the management of Victoria Hospital.  We understand subscriptions are non-refundable.  We agree and accept the entire rule of these schemes and to abide by the rules of the facilities.
Date:                    Signature :

By clicking on SUBMIT you are confirming to having read the SPECIAL DECLARATION and NOTES.