Aviva Ltd 4 Shenton Way #01-01 SGX Centre 2, Singapore 066807 Tel: (65) 6827 7988 Fax: (65) 6827 7401 Company Reg No.: 196900499K GST Reg No.: MR-8500166-8
Group Life & Health Underwriting
MEDICAL EXAMINATION FORM (PART I) - PERSONAL STATEMENT BY THE IMPORTANT NOTE: Pursuant to Section 25(5) of the Insurance Act (Cap. 142), you are to disclose in this form, fully and faithfully, all the facts which you know or ought to know, otherwise, nothing may be payable under the Policy. A.
PARTICULARS OF EXAMINEE (Please complete in capital letters) Occupation and Exact Nature of Duties
Full Name as shown on NRIC/Passport/BC (Underline Surname) *Mr/Mrs/Mdm/Miss/Dr
Email Address: Name and Address of Company
Postal Code Country of Residence:
Age Next Birthday
Date of Birth
Tel No. (H)
D M M Y
EXT Marital Status:
* Please delete accordingly B.
PLEASE ANSWER THE FOLLOWING QUESTIONS (To be answered by the Examinee)
1a. Do you have a regular doctor?
If Yes, please state the name and address of your regular doctor.
1b. Please state the type of illness consulted, date of consultations and the result of such consultations with your regular doctor.
If “Yes”, please give details such as date of onset/test, names & address of doctor, results of investigation, type of treatment, any recurrence/fully recovered.
Are you now receiving, considering receiving medical treatment from a doctor or any intention to consult any doctor for any reason, seek further treatment or alternative medicine?
3. Have you ever undergone any special investigation such as X-ray, ultrasound, electrocardiogram, mammogram, blood or urine test etc. in the past 5 years? (Please state date, reason, type and result of tests done.) If “Yes”, please give details such as date of occurrence, investigation / treatment provided and name / address doctor. 4. Have you ever had, or been told to have or been treated for:a.
epilepsy / fits, stroke, paralysis / weakness of limb, prolonged headache, nervous breakdown, depression or any other nervous / mental disorders?
b. cataract, ear infection / discharge or any other disorders of eye, ear, nose or throat? c. asthma, bronchitis, persistent cough, coughing with blood pneumonia, tuberculosis, breathing complaints/discomfort or any other lung disorders? Aviva: Public d. raised cholesterol, high blood pressure, heart attack, mitral valve prolapse or other heart valve disorders, breathlessness, fast heart rate, chest pain, or any disease or disorders of the heart? 990380 0211
If “Yes”, please give details such as date of occurrence, investigation / treatment provided and name / address doctor. Yes
e. diabetes mellitus, thyroid disorder or any endocrine disease? f.
gastritis, stomach or duodenal ulcer, blood in stools, fistula, piles or any other stomach or bowel disorder?
g. jaundice, hepatitis B carrier or any form of hepatitis, liver or gallbladder disorder? h. blood, protein or sugar in urine, kidney stones, infection or any other disorders of the kidney, bladder or genital organs? i.
cancer, tumour, cyst or growth of any kind?
slipped disc, backache, gout, arthritis, pain or deformity or disorders of the muscles, spines, limbs or joints or severe injury?
k. any sexually transmitted disease, eg syphilis, gonorrhoea, non-specific urethritis, herpes, HIV infection or AIDS? l.
endometriosis, fibroids, cysts, breast lumps, abnormal pap smear, irregular or painful menstruation or any other disorders of the female organs?
m. anaemia, haemophilia or any disorders of the blood? n. any other illnesses, congenital or hereditary disorders, any hospitalisation or physical
5. Have you ever received any blood transfusion or ever been refused as a blood donor? 6. Have you smoked in the past 12 months? If “Yes”, please state numbers of years and the number of sticks per day.
No of Years
7. Do you consume alcohol? If “Yes”, please state the quantity, type and frequency.
No of Sticks/day Type
8. Do you engage in hazardous activity such as aviation (other than as a private paying passenger), scuba/skin diving, motor racing, mountaineering, etc? 9. Do you engage in activities that will increase exposure to AIDS or AIDS related conditions? 10. Have any of your natural parents or siblings died or suffered from (a) heart disease (b) high blood pressure (c) stroke (d) diabetes (e) cancer (f) kidney disease (g) mental disorder (h) muscular disorder or any other hereditary disease? Relationship
Condition/cause of Death
Age at If Deceased, offset Age at Death
On Behalf of myself and dependents, I/we consent to Aviva (and Aviva related group of companies) collecting, using and/ or disclosing my/our personal data to issue and administer my existing and/or new policies or insurance coverage(s) with Aviva On Behalf of myself and my dependents. I/we also consent to Aviva (and Aviva related group of companies) transferring my/our personal data to Aviva related group of companies and/or third party service providers, reinsurers, suppliers or intermediaries, whether located in Singapore or elsewhere, for the above purposes. For full details of the purposes of collection, use and disclosure of your personal data, please Visit http://www/aviva.com.sg/pdpa.html D. I declare that the answers were given by me in reply to the questions put to me and to the best of my knowledge and belief, the information furnished herein are true and complete and I agree that they are in continuation of and form part of my proposal and that failure to disclose any material known fact to me may invalidate the Policy. I agree to inform Aviva Ltd if there is any change in the state of my health or my activities between the date of this Health Declaration/Medical Examination and the date full insurance coverage is provided by Aviva Ltd to me. I understand that the terms of accepting me as a risk for insurance coverage may vary according to such information received. I authorise any medical source, insurance office or organisation to release to Aviva Ltd and similarly Aviva Ltd to release to any of the prior mentioned organisations, relevant information concerning me at any time, irrespective of whether the proposal is accepted by Aviva Ltd. A photographic copy of this authorization shall be as valid as the original. Only applicable to Group Medical products (including Livingcare & Disability Income) for all voluntary and flexible benefits. I/We confirm that I/We have received a copy of Your Guide to Health Insurance and Product Summary and have read and understood the contents of these two documents.
Aviva: Publicof Examinee Signature Date
D D M M
Signature of Medical Examiner
2 0 Y Y
D D M M
2 0 Y Y MED 001/Pg2
MEDICAL EXAMINATION FORM (PART II) - MEDICAL EXAMINER’S CONFIDENTIAL This examination should be in private, without the presence of a third party except as chaperon or interpreter. The medical examiner is requested to send this report in a sealed envelope as it is strictly confidential between the Company and the examiner. Please note that we may be obliged to disclose results of the medical examination to the examinee at his request.
PLEASE ANSWER THE FOLLOWING QUESTIONS (To be answered by the Medical Examiner)
Please give full details of any abnormality
1. Are you personally acquainted with the examinee? If so, in what capacity and please provide details of any consultations?
2. CNS, SKELETAL SYSTEM a) Are there any diseases of the central or peripheral nervous system? b) Are the tendon reflexes abnormal? c) Any paralysis or tremors? d) Any bones or joints deformity, amputation?
3. CHEST a) Are the shape, capacity & expansion of the chest unsatisfactory? b) Are the breath sounds abnormal? If not, please describe the adventitious sounds heard.
4. HEART a) Is the Apex beat abnormal?
PULSE RATE beats/minutes *Regular / Irregular
b) Are there any signs of hypertrophy or dilatation? c) Are there any abnormalities in the heart sounds? d) Are there any murmurs? If Yes, please indicated the grade of murmurs. e) Blood pressure - (if SBP>140, or DBP>90 (5th phase), please take 2 further readings with interval of 5 minutes. If the examinee is hypertensive, please state, if known, the readings with relevant dates.
Systolic(mm Hg) Diastolic(mm Hg) 5th phase
5. ABDOMEN a) Are the liver, spleen, kidneys palpable? b) Are there any abnormal abdominal mass, such as hernia, tumour? c) Are there any symptoms of any digestive disturbances?
6. Are there any diseases of the thyroid or endocrine glands?
7. Are there any Ear, Nose or Throat abnormality?
8. Are there any diseases of the Eyes? Are there any arcus senilis, xanthoma or any stigma of vascular abnormality? VISUAL ACUITY * Aided / Unaided Right Aviva: Public
Distant Near MED 001/Pg3
Yes 9. a)
Please give full details of any abnormality
GENITOURINARY SYSTEM Are there any diseases of the urinary and genital organs? eg. varicocele, calculus.
Female examinee: to indicate LMP when blood is present
URINE EXAMINATION Send specimen for microscopic urinalysis if blood (provided not due to menses) or albumin is present or history of urinary disease. If urine sugar is present, to draw blood for HbA1C and blood sugar (to indicate if it’s fasting or random)
URINE EXAMINATION PH
Put cells or other abnormalities
a) Does he/she has any visible growth, tumour or enlargement? If so, please state its location and its nature. b) Are there any significant changes in his or her appetite, weight and bowel habits recently? If so, please elaborate. c) Are you of the opinion that he/she is particularly exposed to the risk of HIV infection? d) Are there any further medical or information required to enable a correct judgement of the risk
a) Please furnish his/her height & weight.
b) Has the weight *increased, decreased or remained the same during the pass one year? c) Is there any unexplained weight loss? If Yes, please provide reasons for the weight loss.
Please furnish his/her chest and abdomen measurements.
a) & b)
Circumference of chest at nipple level
Circumference of abdomen at umbilicus
In the case of a Female:a) Are there any lumps or lesions in the breasts? b) Are there any obstetrics or gynaecological abnormalities whether past or present? eg. Fibroid, ovarian cyst etc. c) Is she now pregnant? If yes, please give the gestational stage.
Please comment and provide any additional information on the examinee that would assist Aviva’s assessment of the application.
Signature of Medical Examiner
of Examination Aviva:Date Public
D D M M
Name of Medical Examiner
2 0 Y Y
* Please delete accordingly This Report should be sent directly to Group Life & Health Underwriting.