Title GHC Member Application Form.Cus.docx ✅

Name: Name: Declaration I ………………………………………………………… declare that, to the best of my knowledge, the statements in this form are true and correct. I have read the notes contained in this form and understand that they constitute a contract with GLICO HEALTHCARE that, no liability will be accepted for any condition that originated before the date of commencement of the policy, or the date of acceptance of this application, whichever is later in time unless such condition is disclosed on this application form and accepted by GLICO HEALTHCARE. I also agree that GLICO HEALTHCARE may seek any information from any doctor who has attended to me and I authorize the giving of such information. …………………………………………………… …………………………………… Signature of Applicant Date For Illiterate or Person Whom Form is Read to by a Third Party I …………………………………………………………… agree that, the content of this form has been truly and audibly read over and interpreted to me in the …………………………… language by ………………………………………………………… of ………………………………………………………… and I seemed perfectly to understand same and affix my mark in the presence of ………………………………………………………… Mark of Customer/ Mark of Interpreter/ Thumbprint /Signature Thumbprint /Signature …………………… Date Note: 1. Particulars of the dependants who are to be included in the scheme should be furnished, and any dependants who is suffering from any illness or disability on or before the date of this application will not be covered unless such a condition has been disclosed in this form and same accepted by GLICO HEALTHCARE. 2. The obligation of GLICO HEALTHCARE commences only after this application has been accepted by its underwriter. Office Use Only Policy Number Premium Payable Benefits Option Approved By Effective Date