MediSavers Portal - E-Quotation

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Please provide prospect's particulars

1 Does your work involve in extra-hazardous occupation/activities?
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Please select membership package that suit your prospect most at below:

Membership Packages
Quotation Summary
Quotation Summary
Age
Membership
Payment Plan
Membership Tenure
Monthly Recurring Payment RM500 / month for 12 months
Yearly Total RM6,000
* First Time Payment RM1,500
Subtotal RM1,500
* 1 Month Membership + 1 Months Deposit

Please answer questions as below

Has the person to be insured ever:-
  1. had any application or renewal for health policy declined, restricted or accepted at other than normal terms?
  2. had any physical defect, hereditary disease, infirmity or congenital conditions?
  3. been under observation or receiving treatment or taking any medication?
Has the person to be insured ever suffered from or been treated for any of the following:-
  1. Arthritis, Rheumatism, Cancer, Malignant Blood/Leukemia, Diabetes, Fits, Epilepsy, Hepatitis, Heart Attack, Stroke, Thyroid, Maculopathy, Psoriasis, Mental or Nervous Disorder, AIDS or AIDS related Conditions, Sexually Transmitted Diseases.
  2. Rheumatic Fever, Asthma, Bronchitis, Pneumonia, Persistent Cough, Spitting of Blood, Pleurisy, Tuberculosis, Colic, Persistent Abdominal or Gastric Pain, Ulcer, Haemorrhoid, Hernia, Cholecystitis, Stone in Urinary or Biliary System, Jaundice, Persistent Headache, Recurrent Dizziness, Shortness of Breath, Palpitations, Chest Pain, High or Low Blood Pressure, High Cholesterol, Sugar or Blood in Urine, Anemia.
  3. Sciatica, Slipped disc, Gout, Back Pain, Spine, Muscles, Bones, Joints or Knee Disorder, Eczema, Skin Disease, Cataract, Glaucoma, Retinal Detachment or any Other Disease of Eyes, Ears, Nose, Mouth or Throat Disease, Goiter, Glands or Endocrine System disease, Tumour, Cyst, Nodule, Polyp, Lump or Growth of Any Kind in any Organ System, Prostate Enlargement, Disease of Male Genital System.
  4. Any illness, disease or injury not mentioned above
Have the person to be insured ever had any disease or disorder of the breast or female reproductive organ, menstrual disorder, abnormal pap-smear test, or complications at childbirth?
  1. Was the person to be insured born premature?
  2. Has the person to be insured ever been or is currently being investigated or treated for, or have been informed or advised to seek medical or surgical treatment for any complications at birth or within the first 30 days of birth?
Does the person to be insured have any criteria as below:-
  1. any deformity or illness?
  2. been hospitalised for any illness of injury?
  3. undergone any surgical operation?
  4. been advised to have a surgical operation which has yet to be performed?
  5. ever been a carrier of any condition, such as hepatitis, etc?
  6. currently under medication or supervision of a doctor or physician for any illness or disability?
  7. ever had an application for or renewal of a health insurance policy declined or accepted at other than normal terms?
Have you or any persons to be insured:-
  1. ever been declared bankrupt or currently under legal proceeding from insolvency Department or have you convicted in a court of law or currently under legal proceeding in any country?
  2. ever, in respect of any accident insurance, had an insurer defer or decline a proposal, refuse renewal or terminate insurance?
  3. lodged any claims under any accident insurance policy?
  4. suffer from any physical impairment, infirmity or abnormity or congenital conditions?
  5. suffered from any illness or injury which has required any special form of medical or examination or consultantion or hospitalization, or that may require future treatment?
  6. engage in any hazardous activities or pursuits?
  7. have any other policies in force where a similar benefit may be payable?
Is the person to be insured currently insured under any other health insurance policy? If the answer is "Yes", please provide who is the Insurer?
Is the person to be insured had any claim made under health insurance policy with Lonpac or with other insurance company?
Has the person to be insured ever undergone any surgical operation or been advised to have a surgical operation which has not been performed?
Type of Disability
Date of Disability
Type of Treatment
Present State of Disability
Name of Doctor/Hospital
Address of Doctor/Hospital
Please provide details of doctors/clinics which the Person to be Insured had consulted with or currently receiving medical treatment
Has any of your certificate/policy or proposal for family takaful or life, critical illness or health insurance declined, restricted and accepted at other than normal terms.
Have you ever had any of the following conditions or symptoms :
  1. Suffered or have any physical defect, infirmity or congenital conditions?
  2. Had any medical check-up, x-ray scan, blood test, urine test, ECG or currently under observation or receiving treatment or taking any medication?
  3. Undergone any surgical operation or suffered from any disease or injury?
  4. Ever been advised to have a surgical operation which has not been performed?
Have you ever had or been treated for any of the following diseases :
  1. Heart or circulatory diseases, high blood pressure or stroke?
  2. Respiratory disorders, asthma or tuberculosis?
  3. Cancer, tumour or growth of any kind?
  4. Diabetes, any disorder of the endocrine system, lymphatic system, brain or nervous system?
  5. Digestive system disorders, stomach, intestine, gall bladder, liver or hepatitis?
  6. Genitourinary or kidney disorder?
  7. Mental or psychiatric condition, depression or epilepsy?
  8. Arthritis, Disorder of the spine, back, joints, bones, muscles or any physical defects or health impairment, any disorder of the skin, eyes, nose, ears, throat or vocal cords?
  9. Anaemia or blood disorder or thyroid disorder?
  10. Alcoholism, drug habits or used habit forming drugs?
  11. AIDS, HIV infection or a positive test for HIV or any sexually transmitted diseases?
  12. Any illness, disease or injury not mentioned above?
Is the child born premature or pre-term?
Do you have more than one family member (natural parents, brothers or sisters) who has suffered from cancer, heart diseases, stroke, diabetes, kidney diseases, mental disorder or any hereditary diseases before the age of 60?

Getting to Know You Prospect Better

Please review your prospect summary

Details of Prospect's Parent/Guardian
No name
No NRIC / passport
No DOB
No nationality
No gender
No marital status
No race
Details of Prospect
No name
No NRIC / passport
No DOB
No nationality
No gender
No race
No address 1 No address 2
No address 3 No postcode No city / town
No state
No telephone number
No mobile number
No email
Emergency Contact Info
No emergency contact name
No emergency contact number
Lonpac Questionnaire
No
Insurer
No
  1. had any physical defect, hereditary disease, infirmity or congenital conditions?
    No
  2. been under observation or receiving treatment or taking any medication?
    No
  3. undergone any surgical operation or been advised to have a surgical operation which has not been performed?
    No
    Type of Disability
    Date of Disability
    Type of Treatment
    Present State of Disability
    Name of Doctor / Hospital
    Address of Doctor / Hospital
  1. Arthritis, Rheumatism, Cancer, Malignant Blood/Leukemia, Diabetes, Fits, Epilepsy, Hepatitis, Heart Attack, Stroke, Thyroid, Maculopathy, Psoriasis, Mental or Nervous Disorder, AIDS or AIDS related Conditions, Sexually Transmitted Diseases.
    No
  2. Rheumatic Fever, Asthma, Bronchitis, Pneumonia, Persistent Cough, Spitting of Blood, Pleurisy, Tuberculosis, Colic, Persistent Abdominal or Gastric Pain, Ulcer, Haemorrhoid, Hernia, Cholecystitis, Stone in Urinary or Biliary System, Jaundice, Persistent Headache, Recurrent Dizziness, Shortness of Breath, Palpitations, Chest Pain, High or Low Blood Pressure, High Cholesterol, Sugar or Blood in Urine, Anemia.
    No
  3. Sciatica, Slipped disc, Gout, Back Pain, Spine, Muscles, Bones, Joints or Knee Disorder, Eczema, Skin Disease, Cataract, Glaucoma, Retinal Detachment or any Other Disease of Eyes, Ears, Nose, Mouth or Throat Disease, Goiter, Glands or Endocrine System disease, Tumour, Cyst, Nodule, Polyp, Lump or Growth of Any Kind in any Organ System, Prostate Enlargement, Disease of Male Genital System.
    No
No
  1. Are you currently pregnant?
    No
  2. Have you ever had any disease or disorder of the breast or female reproductive organ, menstrual disordder, abnormal pap-smear test, or complications at childbirth?
    No
  1. Was the child born premature?
    No
  2. Has the child ever been or is currently being investigated or treated for, or have been informed or advised to seek medical or surgical treatment for any complications at birth or within the first 30 days of birth?
    No
I have none
Doctor / Clinic 1
I have none

Doctor / Clinic 2


Doctor / Clinic 3


MediSaversVIP Ehsan Questionnaire
No
No
No
No
No
No
No
I have no usual doctor

STM Questionnaire
No
  1. Suffered or have any physical defect, infirmity or congenital conditions?
  2. Had any medical check-up, x-ray scan, blood test, urine test, ECG or currently under observation or receiving treatment or taking any medication?
  3. Undergone any surgical operation or suffered from any disease or injury?
  4. Ever been advised to have a surgical operation which has not been performed?
No
  1. Heart or circulatory diseases, high blood pressure or stroke?
  2. Respiratory disorders, asthma or tuberculosis?
  3. Cancer, tumour or growth of any kind?
  4. Diabetes, any disorder of the endocrine system, lymphatic system, brain or nervous system?
  5. Digestive system disorders, stomach, intestine, gall bladder, liver or hepatitis?
  6. Genitourinary or kidney disorder?
  7. Mental or psychiatric condition, depression or epilepsy?
  8. Arthritis, Disorder of the spine, back, joints, bones, muscles or any physical defects or health impairment, any disorder of the skin, eyes, nose, ears, throat or vocal cords?
  9. Anaemia or blood disorder or thyroid disorder?
  10. Alcoholism, drug habits or used habit forming drugs?
  11. AIDS, HIV infection or a positive test for HIV or any sexually transmitted diseases?
  12. Any illness, disease or injury not mentioned above?
No
No
No
PASavers Questionnaire
No
No
No
No
No
No
No
Membership Advisor Details
No name
No NRIC / passport
No DOB
No nationality
No gender
No race
No address 1 No address 2
No address 3 No postcode No city / town
No state
No telephone number
No mobile number
No email
No marital status
No bank
No bank account no
Membership Program
#
Program Name
Total Amount





Staff

  • 8
    ...

    Bob Nilson

    Project Manager
  • ...

    Nick Larson

    Art Director
  • 3
    ...

    Deon Hubert

    CTO
  • ...

    Ella Wong

    CEO

Customers

  • 2
    ...

    Lara Kunis

    CEO, Loop Inc
    Last seen 03:10 AM
  • new
    ...

    Ernie Kyllonen

    Project Manager,
    SmartBizz PTL
  • ...

    Lisa Stone

    CTO, Keort Inc
    Last seen 13:10 PM
  • 7
    ...

    Deon Portalatin

    CFO, H&D LTD
  • ...

    Irina Savikova

    CEO, Tizda Motors Inc
  • 4
    ...

    Maria Gomez

    Manager, Infomatic Inc
    Last seen 03:10 AM
Bob Nilson 20:15 When could you send me the report ?
Ella Wong 20:15 Its almost done. I will be sending it shortly
Bob Nilson 20:15 Alright. Thanks! :)
Ella Wong 20:16 You are most welcome. Sorry for the delay.
Bob Nilson 20:17 No probs. Just take your time :)
Ella Wong 20:40 Alright. I just emailed it to you.
Bob Nilson 20:17 Great! Thanks. Will check it right away.
Ella Wong 20:40 Please let me know if you have any comment.
Bob Nilson 20:17 Sure. I will check and buzz you if anything needs to be corrected.

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