Monthly Huruyadzo/Ezinkulu Plus

3: REGISTRATION OR ADDITION OF DEPENDENTS Spouse/Child/Newborn/Adult dependent

2ND DEPENDENTS

3RD DEPENDENTS

4TH DEPENDENTS

5TH DEPENDENTS

6TH DEPENDENTS

3: MEDICAL HISTORY It is compulsory to answer each question. Failure to disclose medical conditions could limit and/or exclude you or your dependents from receiving certain benefits or result in termination of your membership.

1. Any Chronic illnesses. Cardio and Vascular conditions, Obstructive lung diseases, Diabetes, High or Low blood pressure, Raised Cholesterol Asthma, Depression, Anxiety, Systematic lupus erythematosus, Epilepsy, Thyroid disorders? If yes, please provide details.

2. Digestive system or Stomach disorders? Liver failure, Gall bladder or pancreas, Stomach or duodenal ulcer, Hiatus hernia, Crohn’s disease, Irritable bowel syndrome, Rectal bleeding, Hepatitis. If yes, please provide details

3. Muscle, Bone, Dental, Orthodontic condition, Skin or nerve illness or disorders. Acne, Eczema or psoriasis, Multiple sclerosis, Back injury/neck or joint problems or replacements, Arthritis, Prosthetic limbs, Gout, Stroke, Blackouts, Migraine, Alzheimer’s etc. If yes, please provide details

4. Urinary tract, genital /Gynaecological disorders? E.g. UTI, Kidney stones, Kidney Failure, Prostatitis, Ovarian cysts, Fibroids, etc., If yes please provide details.

5. Blood disorders, Cancer, etc.? If yes, please provide details.

6. Ear, Nose, Throat or Eye disorders? Defective vision, Cataracts, Glaucoma, Blindness, Retinitis, wear spectacles or contact lenses, Hearing loss, Ear discharge, Allergies, recurrent Tonsillitis, etc. If yes, please provide details.

7. Are you or any of your dependents pregnant? If yes, please provide details

8. Have you or any of your dependents had surgery in the past 12 months, or are you planning to have surgical procedure in the next 12 months? Or any other condition not stated above? If yes, please provide details.

9. Is anyone on regular medications? If yes please list them

HOW IT WORKS

1. ENROLLMENT

2. COMMENCEMENT OF COVER

3. PREMIUM PAYMENT

4. CLAIMING OF MEDICINE

5. MEMBERSHIP Policy Certificate

Terms And Conditions

5: MEDICAL HISTORY