Africa Wellness Solutions Switch Form
Download a blank fillable Africa Wellness Solutions Switch Form in PDF format just by clicking the "DOWNLOAD PDF" button.
Open the file in any PDF-viewing software. Adobe Reader or any alternative for Windows or MacOS are required to access and complete fillable content.
Complete Africa Wellness Solutions Switch Form with your personal data - all interactive fields are highlighted in places where you should type, access drop-down lists or select multiple-choice options.
Some fillable PDF-files have the option of saving the completed form that contains your own data for later use or sending it out straight away.
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4AFRICA WELLNESS SOLUTIONS
A F R I C A
SWITCH FORM
WELLNESS
SOLUTIONS
DEVELOPED IN AFRICA,
PROTECTING YOU
GLOBALLY
PLEASE COMPLETE THIS FORM IN BLOCK CAPITALS
Are you applying as an individual or as a member of a company group?
Individual
Company
Please state the name of the company
Important notes
In order to ensure confidentiality, please send your health questionnaire and any/all medical documents in a sealed envelope marked
«confidential» for the attention of JWS Africa Healthcare Services, Suite 1103 11th Floor, The Core, 162 ICT Avenue, Cybercity, Ebene,
Republic of Mauritius. (Please note that the application process will be longer as a result of using postal services.)
It is highly recommended that you send your questionnaire in this way if you’ve answered YES to at least one of the questions. If you prefer,
you can also send your questionnaire and any/all medical documents to the medical department of JWS Africa Healthcare Services via email to
.
Definitions
Home Country: this is the country for which you hold a passport
Principal Country of Residence: this is the country where you are living for most of the year
Elected Country: this is the country of your choice where you would wish to be treated for a major surgical intervention – please see the policy
wording for further details.
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Applicant details
You must notify us of any change of contact details so we can ensure that correspondence reaches you.
We will consider applicants for cover under the age of 75.
Mr.
Mrs.
Ms.
Miss.
First name:
Surname:
Date of birth:
DD/MM/YYYY
Gender: Male
Female
Home country:
Nationality:
Principal country of residence:
Full address in principal country of residence (mandatory):
Primary phone number:
COUNTRY CODE – AREA CODE
Secondary phone number:
COUNTRY CODE – AREA CODE
Email address (mandatory, please print):
Occupation (mandatory); please state if student:
Details of current domestic or international health insurance
Name of insurer:
Start date:
DD/MM/YYYY
Policy number:
Underwritten by:
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Parent category: Legal