MEMBERSHIP APPLICATION FORM

Instructions:
1. Please complete in BLOCK CAPITALS marking the appropriate box(es) with an X New Renewal
2. This Application Form must be fully completed Upgrade
Downgrade
Section 1: of Main Member
Section 1: Detailsils of Main Member
Title: Mr Mrs Ms

Member Surname:

Member First Name:

Gender: Male Female

Date of Birth: D D ID M M Y Y Y Y
Number: Please provide us with a copy

Name of Company:

Employee Number (Corporate Clients Only):

Date of employment: Date of Con rmation: (Company Seal & HR Signature Mandatory)
Marital Status: Occupation:

Residential Address:

Phone Number: Home Mobile

Email Address:

Plan Chosen:
Bank Details of Main Member for Claims Refund
Bank Details of Main Member for Claims Refund

Bank Name:

Bank Account Number:

SectionSection2:2: PolicyPolicyDetailsDetails
Cover Start Date: DDMMYYYY
Method of Payment:
Annually (Specify Mode of Payment):

Monthly (Specify Mode of Payment):

SectionSection3:3: DependaendantsntstotobebeCoveredCovered
You may include your Spouse/Partner under the age of 65 and unmarried children under the age of 25 if in full time education
(Proof should be provided). Should you require more space, please continue on a separate sheet and attach it to this application.

Details Dependent 1 Dependent 2 Dependent 3 Dependent 4

Title Mr Mrs Miss Mr Mrs Miss Mr Mrs Miss Mr Mrs Miss

Dependant Surname

Dependant First Name

Gender

Date of Birth DD/MM/ YYYY DD/MM/ YYYY DD/MM/ YYYY DD/MM/ YYYY
ID Number

Nationality

Relation to Member

Plan Chosen

Eagle Insurance Limitedc/o Medscheme T: +230 460 9208

BRN: C06002277 1st Floor, Tower A , 1Cybercity E: health@eagle.mu
eagle.mu Ebene , Mauritius
Eagle Insurance

Administered by A member of IBL

MEMBERSHIP APPLICATION FORM

SectionSection4:4: Adultlt MembersMembersPhysicalPhysicalDetailsDetails

Self Spouse
Weight
Height

Waist

Hip

Self Dep 1 Dep 2 Dep 3 Dep 4

Does any of the applicant smoke?

If yes, please specify daily consumption.

Does any of the applicant consume alcohol?

If yes, please specify daily consumption.

Does any of the applicant practice any physical exercise?

If yes, please specify which exercise and where.

SectionSection5:5: MediicalcalHistoryHistory
It is compulsory to answer all the questions listed below, if not the application will be considered incomplete.

No in the boxes provided below.

Self Dep 1 Dep 2 Dep 3 Dep 4

1 High Blood Pressure, Vascular Disease and/or Heart Disease

2 Diabetes

3 Malignant Disease of any Kind

4 Lungs Disease and/ or Respiratory System Conditions

5 Liver and/ or Digestive System Conditions

6 Kidneys and/ or Bladder Conditions

7 Sexually Transmissible Disease

8 Reproductive System Conditions (Male & Female)

Eagle Insurance c/o Medscheme T: +230 460 9208

Limited BRN: 1st Floor, Tower A , 1Cybercity E: health@eagle.mu
C06002277 eagle.mu Ebene , Mauritius
Eagle Insurance

Administered by A member of IBL

MEMBERSHIP APPLICATION FORM

Self Dep 1 Dep 2 Dep 3 Dep 4

9 Nervous System

10 Breast Problems

11 Dental System

12 Eye, Ear, Nose and/or Throat

13 Intervertebral Disease
14 Have any of the applicants been treated and/ or admitted as an Inpa-tient in a Clinic
and/or Hospital?
15 Have any of the applicants been advised to follow in the future a

16 Are any of the applicants currently pregnant? If so, please provide the expected
date of delivery.

17 Any other Diseases/Illnesses/Conditions not mentioned above

18 Any other Illnesses, Disabilities, and/or Accidents lasting more than 15 days during
the past 2 years

Please give full particulars together with a copy of medical reports available if any of the answers to nos. 1 – 16 above is a Yes.

Nature of Illness/ Date of First

Question No. Name Attending Doctor Duration
Condition/ Injury Occurrence

SectionSection6:6: OthererInsuranceInsuranceCoversCovers
Do you or any of your dependants have one of the following covers:

Other Medical Insurance. Yes No

If yes, please provide Full Details:

Insured Name:

Name of Insurer:

Amount Covered:

Eagle Insurance Limitedc/o Medscheme T: +230 460 9208

BRN: C06002277 1st Floor, Tower A , 1Cybercity E: health@eagle.mu
eagle.mu Ebene , Mauritius
Eagle Insurance

Administered by A member of IBL

 MEMBERSHIP APPLICATION FORM

Personal Accident Cover

If yes, please provide Full Details:

Insured Name:

Name of Insurer:

Amount Covered:

Any other Insurance related to Medical?

If yes, please provide Full Details:

Insured Name:

Name of Insurer:

Amount Covered:

Section 7:
I apply for the enrolment with the inclusion of any Dependant listed in Section 3. I declare that the answers and information given
by me in this application form are true and complete and that I have not withheld any information in regard to this application that
ought to be disclosed.
By signing this document, I expressly authorise the scheme to carry out all necessary investigations, have access to any medical
reports, results and any related information for myself (and any dependent covered) without my consent.

Main Member Dep 1 Signature Dep 2 Signature Dep 3 Signature Dep 4 Signature
Signature (If over 18) (If over 18) (If over 18) (If over 18)

Date: D D M M Y Y Y Y

Note:

Membership Application Form .

This form once completed should be sent to: Membership Card: You can use your electronic card on
the mobile application, Medscheme Touch, which can be
EAGLE INSURANCE LIMITED,
c/o Medscheme, 1st Floor, Tower A, downloaded on both the App Store & Google Play Store. A
1Cybercity, Ebene physical card is also available at the unit price of Rs 100.
Please tick this box if you would like to request same.

Eagle Insurance and Medscheme would love to send you great promotional o ers and the latest info from Eagle Insurance by email, post, sms,
phone and other electronic means. we’ll always treat your personal details with the utmost care and will never sell them to other companies for
marketing purposes. Please tick the box below if you would not like to hear from us.

Eagle Insurance Limitedc/o Medscheme T: +230 460 9208

BRN: C06002277 1st Floor, Tower A , 1Cybercity E: health@eagle.mu
eagle.mu Ebene , Mauritius
Eagle Insurance

Administered by A member of IBL