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Quaterly Pachedu/Sisodwa

Quaterly Pachedu/Sisodwa

$57.00 for each 3 months

COVERS UP TO 3 PEOPLE
COVERS FOR DOCTOR CONSULTATION,
ACUTE MEDICATION,
DENTAL CONSULTATION,
HOSPITALISATION CASH-BACK
PREMIUM: USD$19

Step 1 of 4

25%

Name*
First Last
Nationality*
First
Date Of Birth*
DD slash MM slash YYYY
Gender
- Male
- Female
- Other
Marital Status
- Single
- Married
- Widow
- Other

2: REGISTRATION OR ADDITION OF DEPENDENTS Spouse/Child/Newborn/Adult dependent
Name
FirstName Surename
Date Of Birth
DD slash MM slash YYYY
RELATIONSHIP
GENDER
- Male
- Female
- Other
ID NUMBER for 18yr & above
List of medications if any
2ND DEPENDENTS
Name
FirstName Surename
Date Of Birth
DD slash MM slash YYYY
RELATIONSHIP
GENDER
- Male
- Female
- Other
ID NUMBER for 18yr & above
List of medications if any
3RD DEPENDENTS
Name
FirstName Surename
Date Of Birth
DD slash MM slash YYYY
RELATIONSHIP
GENDER
- Male
- Female
- Other
ID NUMBER for 18yr & above
List of medications if any

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.
Name of Beneficiary
Name of Condition and date diagnosed
Are you currently receiving treatment?
Date of last treatment
Name of Medication
Attending GP/Specialist (YES/ NO)
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
Name of Beneficiary
Name of Condition and date diagnosed
Are you currently receiving treatment?
Date of last treatment
Name of Medication
Attending GP/Specialist (YES/ NO)
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
Name of Beneficiary
Name of Condition and date diagnosed
Are you currently receiving treatment?
Date of last treatment
Name of Medication
Attending GP/Specialist (YES/ NO)
4. Urinary tract, genital /Gynaecological disorders? E.g. UTI, Kidney stones, Kidney Failure, Prostatitis, Ovarian cysts, Fibroids, etc., If yes please provide details.
Name of Beneficiary
Name of Condition and date diagnosed
Are you currently receiving treatment?
Date of last treatment
Name of Medication
Attending GP/Specialist (YES/ NO)
5. Blood disorders, Cancer, etc.? If yes, please provide details.
Name of Beneficiary
Name of Condition and date diagnosed
Are you currently receiving treatment?
Date of last treatment
Name of Medication
Attending GP/Specialist (YES/ NO)
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.
Name of Beneficiary
Name of Condition and date diagnosed
Are you currently receiving treatment?
Date of last treatment
Name of Medication
Attending GP/Specialist (YES/ NO)
7. Are you or any of your dependents pregnant? If yes, please provide details
Name of Beneficiary
Expected Date of Delivery
Attending GP/Specialist
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.
Name of Beneficiary
Name of Condition and date diagnosed
Are you currently receiving treatment?
Date of last treatment
Name of Medication
Attending GP/Specialist (YES/ NO)
9. Is anyone on regular medications? If yes please list them
Name of Beneficiary
Name of Medication
Attending GP/Specialist (YES/ NO)

HOW IT WORKS
1. ENROLLMENT
Those who wish to join the VITEQS Medicine Insurance Policy fill in all the required details in full.
2. COMMENCEMENT OF COVER
Cover commences after 3 calendar months waiting period from commencement date of the policy.
3. PREMIUM PAYMENT
a) Premiums are paid monthly, quarterly, half-yearly or annually in advance. b) Thirty (30) days grace period is allowed for late payment of premiums after which the policy shall lapse. c) The policy can be revived within a period of three calendar months subject to a waiting period of one month.
4. CLAIMING OF MEDICINE
a) When you get a prescription from your Dr or hospital simply send it to VITEQS. b) VITEQS processes and contacts you to pick up your medications in a timely manner. c) VITEQS will source the required medications, if VITEQS fails to source the medications the equivalent sum will be reimbursed.
5. MEMBERSHIP Policy Certificate
The membership certificate will be sent to you via email or post, keep it in a safe place. No other cards shall be issued to your dependants as your membership policy number shall be used for claiming benefits on their behalf.
Terms And Conditions
This form should be completed by applicants joining VITEQS Medicine Insurance Policy for the first time or dependents now wishing to join as principal members. This form can be completed as well if you are member of VITEQS Medicine Insurance Policy and wish to add or remove a dependent or change from one plan to another. For new applications all sections are mandatory.
5: MEDICAL HISTORY
You need to inform the Society, if you or any of the family members you are registering is currently undergoing or likely to require medical treatment. It is very important that you disclose all information here as failure to do so may result in your membership being terminated.
Acknowledgement*
• As a member l agree to the operating terms and conditions of VITEQY. • I acknowledge that l am familiar with the benefits included in my chosen package.
Declaration and Signature*
• I hereby declare that the information given is true and correct. Signed:

Quaterly Pachedu/Sisodwa quantity

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