THE LAFERLA MEDICAL TREATMENT COVER
Covers You for private treatment received in Malta as well as worldwide subject to the limits detailed hereunder

PROPOSAL / QUOTATION FORM

The Laferla Healthplans offer an exceptional combination of excellent cover at excellent rates. They are underwritten by Middle sea Insurance p.l.c., a company authorised under the Insurance Business Act. 1998
IMPORTANT NOTE
Insurers, their Agents and Insurance Association share with each other to prevent fraudulent claims and for underwriting purposes. In the event of a claim, some or all of the information you supply in this form and in the claim form together with their information relating to the claim may be provided to Other Insurers, their agents and Insurance Associations.
1.  Insured's Details
Title.
Mr. Mrs. Miss. Ms. Dr. Other 
Surname Full Forenames
Address  Telephone No. 
Date of Birth 
Sex Age at Entry 
Marital Status  I.D. Card No.
E-Mail Address  Occupation
2.  Cover Required
Tick the cover you require

The LAFERLA Medical Treatment
Option 1 - In-patient, Day-case, &  Outpatients Cover (Benefits 1-19)
Option 2 - In-patient, Day-case Cover Only (Benefits 1-13)
3.  Persons to be included in this Application
     All Persons must reside at the applicant's address
Surname Forename Date of Birth Age at Entry I.D. Card No. Relationship
with Insured		 Occupation
4.  Medical History
Have you or any dependants included in this application form and applying for medical  Insurance ever:  Yes  No
1.  consulted a medical practitioner and been provided with prescriptions for any drugs or medication within the last two years?
2. consulted a specialist in the last two years in connection with an actual or suspected medical condition?
3. been admitted in hospital or nursing home within the last four years? 
4. suffered from a chronic or long-term medical or dental condition?
5. suffered from some form of disability, recurrent illness or injury? 
6. been refused medical health insurance?
7. suffered from impaired physical  health?
8. suffered from impaired mental health?
9. Are there any facts or circumstances not mentioned above which may influence our consideration of your proposal?

If you have answered "Yes" to any of the questions 1-9, please give full details in the space provided hereunder:
 

Name Question Medical Condition Date/s of Diagnosis Treatment received Does the Medical
Condition still exists
If there is insufficient space please use here:


 
Name and address of your family's usual medical practitioner.  (G.P)
5.  Commencement of Cover and Method of Payment.
Cover for this insurance will commence : on acceptance or by Date
I would like to pay my premium by: Cash  Local cheque Foreign Cheque 
Credit Card  Type of Card
Card No. 
Expiry Date 
6. Declaration
I, the proposer, on behalf of myself and any dependants shown above, declare that the information given is true and accurate and that  I/we have not witheld any material facts and I/we understand that this information shall be the basis of my insurance cover.
I/we further declare that I/we shall be bound by the rules and conditions of this insurance.
I/we further declare that I/we have no objection and hereby instruct and authorise such person(s) and organisation(s) to provide the company information and not to withhold any information which in the opinion of the Company might be relevant to its needs. Furthermore, I/we agree to reimburse the Company with any costs should such costs arise as a result of the withholding of information and/or the provision of incomplete or incorrect information by me/us and any persons or organisations providing information on my/our behalf as aforesaid
 
 
Name of applicant  Date 

 


Policy Definitions What is Covered & How to claim Premium Rates

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