48 Cocoa Street Teshie – Nungua Estate, Accra-Ghana
Tel:+233 (0) 302-721727, +233 (0) 302-721728+233 (0) 204-333555, +233 (0) 204-333556
Email:info@premiermutualhealth.com
Website:
www.premiermutualhealth.com
 
HEALTH CARE PLAN REGISTRATION FORM
Applicant Payee


MEDICAL HISTORY (Please Underline or Circle the appropriate Medical Condition applicable to you)
BENEFICIARY 1

    MEDICAL HISTORY (Please STATE The Numbers to the appropriate Medical Conditions applicable to beneficiary with reference to the list on the first page.


I HEREBY DECLARE THAT THE INFORMATION I HAVE GIVEN ABOUT ME OR BENEFICIARY IS TRUE.

I UNDERSTAND THAT, ANY MEDICAL HISTORY KNOWN TO ME THAT IS NOT DISCLOSED ABOUT ANY OF MY BENEFICIARIES MAY INVALIDATE THE POLICY.

BY THIS DECLARATION, I AUTHORIZE PREMIER MUTUAL HEALTH. TO RECEIVE PREMIUMS AND TO OBTAIN ANY INFORMATION IT DEEMS RELEVANT TO THIS PROPOSAL FROM ANY PERSON. BY SIGNING THIS DECLARATION, I CONFIRM THAT, I HAVE READ AND UNDERSTOOD THESE DECLARATIONS AND ACKNOWLEDGE RECEIPT OF THE POLICY TERMS AND CONDITIONS.