2.
Have you, or any member of your family, been treated, hospitalized, or operated in a hospital, nursing home, clinic, or other health organization for the last five years? Or in need of hospital treatment within the next 12 months? (*)
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3.
In the past 05 years, you or any member of your family has contracted or treated one or more of the following conditions: TB, diabetes, rheumatoid arthritis, hepatitis, respiratory dysfunction, heart disease, varicose veins, intestinal disorders, liver disease, bile, kidney, genitourinary system or urinary tract diseases, cancer or tumors, neurological, bone marrow, joint, ligaments, muscle, skin, hernia or gynecological disease? (*)
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Commitment
1.
I certify that my / my insured person is in good health, free from neurological or psychiatric illness at any time of the illness, injury or permanent disability of 50% or more.
2.
I certify that the information given above is complete and accurate to the best of my knowledge. I agree that this Insurance Application together with the full payment of premiums will form the basis of the Insurance Agreement between me / us and PJICO and accept the terms and conditions of the policy . I acknowledge that, in the event of any errors or inaccuracies in this Application form, this may invalidate the Policy.
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