Health Insurance Proposal Form

Prepare a policy submission with proposer identity, income, nominee details and up to six lives to be insured. Each person's height, weight, relationship and pre-existing conditions are recorded separately. Agents and underwriters get everything needed to issue cover.

Use this template

Page 1

Proposer name

Nombre

Apellido

Date of birth

Mobile number

Address as shown on your government ID

Dirección

Ciudad

Estado / Provincia

Código postal

Correspondence address

Dirección

Ciudad

Estado / Provincia

Código postal

Highest qualification

Annual income

Nominee name

Nominee's relationship to the proposer

Page 2

Number of people to insure, including yourself

Insured person 1 - full name

Nombre

Apellido

Insured person 1 - date of birth

Insured person 1 - gender

Insured person 1 - height in cm

Insured person 1 - weight in kg

Insured person 1 - relationship to the proposer

Insured person 1 - pre-existing medical conditions

Insured person 1 - description of the medical condition

Insured person 2 - full name

Nombre

Apellido

Insured person 2 - date of birth

Insured person 2 - gender

Insured person 2 - height in cm

Insured person 2 - weight in kg

Insured person 2 - relationship to the proposer

Insured person 2 - pre-existing medical conditions

Insured person 2 - description of the medical condition

Insured person 3 - full name

Nombre

Apellido

Insured person 3 - date of birth

Insured person 3 - gender

Insured person 3 - height in cm

Insured person 3 - weight in kg

Insured person 3 - relationship to the proposer

Insured person 3 - pre-existing medical conditions

Insured person 3 - description of the medical condition

Insured person 4 - full name

Nombre

Apellido

Insured person 4 - date of birth

Insured person 4 - gender

Insured person 4 - height in cm

Insured person 4 - weight in kg

Insured person 4 - relationship to the proposer

Insured person 4 - pre-existing medical conditions

Insured person 4 - description of the medical condition

Insured person 5 - full name

Nombre

Apellido

Insured person 5 - date of birth

Insured person 5 - gender

Insured person 5 - height in cm

Insured person 5 - weight in kg

Insured person 5 - relationship to the proposer

Insured person 5 - pre-existing medical conditions

Insured person 5 - description of the medical condition

Insured person 6 - full name

Nombre

Apellido

Insured person 6 - date of birth

Insured person 6 - gender

Insured person 6 - height in cm

Insured person 6 - weight in kg

Insured person 6 - relationship to the proposer

Insured person 6 - pre-existing medical conditions

Insured person 6 - description of the medical condition

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