Mexican Health Insurance Application

1. Contracting Party Information *

Do you have an FM3?
Choice of deductible from
$1,000 to $60,000 Pesos
If your place of residence is different than your mailing address, please indicate the following:
Yes No
CONTINUITY INSURANCE

If you have a policy with this company or any other company with one year minimal, uninterrupted, and with an open period of less than 30 natural days of the date of stamp receipt from PLAN DE SEGURO, S.A. DE. C.V., please attach a copy of the last policy in force and/or individual certificate, as well as the paid stamped receipt or proof of payment or seniority proof issued by the previous company, so that PLAN DE SEGUROS, S.A. DE C.V. can grant this benefit.
Yes No

2. Applicants *

Please type detailed information regarding the applicant members.

Holder

Do you practice any sport professionally?

Spouse or partner

Do you practice any sport professionally?

Dependent 1

Do you practice any sport professionally?

Dependent 2

Do you practice any sport professionally?

Dependent 3

Do you practice any sport professionally?

Dependent 4

Do you practice any sport professionally?

3. Habits *

Applicants

Holder

Frequency and amount per day
Frequency and amount per day
Frequency and amount per day

Spouse or partner

Frequency and amount per day
Frequency and amount per day
Frequency and amount per day

Dependent 1

Frequency and amount per day
Frequency and amount per day
Frequency and amount per day

Dependent 2

Frequency and amount per day
Frequency and amount per day
Frequency and amount per day

Dependent 3

Frequency and amount per day
Frequency and amount per day
Frequency and amount per day

Dependent 4

Frequency and amount per day
Frequency and amount per day
Frequency and amount per day

4. Other Activities *

Because of your occupation, are you exposed to any of the following: use of fire arms,explosives, heavy machinery, light machinery of high risk, dangerous chemical substances,radiation, heights, high voltage, risk of biological material, transport in a motorcycle?

Holder

Spouse or partner

Dependent 1

Dependent 2

Dependent 3

Dependent 4

5. Medical Questionnaire *

Please indicate in the corresponding space if any of the applicants to insure has or have had any of the following:

Holder

1. Heart disease or hypertension (infarct, aneurysm, angina pectoris, atherosclerosis, other

2. Respiratory system disease (Tb, bronchitis, emphysema, asthma or sinusitis, other

3. Endocrine or metabolic disease (diabetes mellitus, thyroid, hypophysis or obesity

4. Blood disease (anemia or hemorrhage)

5. Circulatory system disease (varices, hemorrhoids, other)

6. Cancer or tumors

7. Any cerebral disease or nervous system disease (paralysis, convulsions, loss of conscience

8. Digestive system disease (esophagus, stomach, intestines, liver (hepatitis), biliary vesicle, pancreas, spleen, rectum, others

9. Urinary system disease (renal calculi, prostate enlargement, recurrent infections, other)

10. Auditory system alterations, skin problems, ophthalmological problems

11. Bone disease, joints, vertebral column, deformities, loss of a limb

12. Sexually transmitted disease, HIV, syphilis or human papillomavirus

13. Any illness or accident not specified on this medical questionnaire

14. Have you ever been hospitalized for a surgery, illness or accident?

15.Have you had any medical symptoms or pain in the last 90 days?

16.In the last 90 days have you visited the doctor for any treatments or made a program or plans for rehab or surgery?

17.In the last 90 days have you had any lab tests, x-rays, tomography, or ultra sounds done?

FOR WOMEN ONLY
18.Have you had any medical treatments or surgery related with your ovaries, uterus, or menstruation?

19.Have you been pregnant?

20. Did you have any problems or complications for your previous pregnancies?

21. Are you currently pregnant?

Spouse or partner

1. Heart disease or hypertension (infarct, aneurysm, angina pectoris, atherosclerosis, other

2. Respiratory system disease (Tb, bronchitis, emphysema, asthma or sinusitis, other

3. Endocrine or metabolic disease (diabetes mellitus, thyroid, hypophysis or obesity

4. Blood disease (anemia or hemorrhage)

5. Circulatory system disease (varices, hemorrhoids, other)

6. Cancer or tumors

7. Any cerebral disease or nervous system disease (paralysis, convulsions, loss of conscience

8. Digestive system disease (esophagus, stomach, intestines, liver (hepatitis), biliary vesicle, pancreas, spleen, rectum, others

9. Urinary system disease (renal calculi, prostate enlargement, recurrent infections, other)

10. Auditory system alterations, skin problems, ophthalmological problems

11. Bone disease, joints, vertebral column, deformities, loss of a limb

12. Sexually transmitted disease, HIV, syphilis or human papillomavirus

13. Any illness or accident not specified on this medical questionnaire

14. Have you ever been hospitalized for a surgery, illness or accident?

15.Have you had any medical symptoms or pain in the last 90 days?

16.In the last 90 days have you visited the doctor for any treatments or made a program or plans for rehab or surgery?

17.In the last 90 days have you had any lab tests, x-rays, tomography, or ultra sounds done?

FOR WOMEN ONLY
18.Have you had any medical treatments or surgery related with your ovaries, uterus, or menstruation?

19.Have you been pregnant?

20. Did you have any problems or complications for your previous pregnancies?

21. Are you currently pregnant?

Dependant 1

1. Heart disease or hypertension (infarct, aneurysm, angina pectoris, atherosclerosis, other

2. Respiratory system disease (Tb, bronchitis, emphysema, asthma or sinusitis, other

3. Endocrine or metabolic disease (diabetes mellitus, thyroid, hypophysis or obesity

4. Blood disease (anemia or hemorrhage)

5. Circulatory system disease (varices, hemorrhoids, other)

6. Cancer or tumors

7. Any cerebral disease or nervous system disease (paralysis, convulsions, loss of conscience

8. Digestive system disease (esophagus, stomach, intestines, liver (hepatitis), biliary vesicle, pancreas, spleen, rectum, others

9. Urinary system disease (renal calculi, prostate enlargement, recurrent infections, other)

10. Auditory system alterations, skin problems, ophthalmological problems

11. Bone disease, joints, vertebral column, deformities, loss of a limb

12. Sexually transmitted disease, HIV, syphilis or human papillomavirus

13. Any illness or accident not specified on this medical questionnaire

14. Have you ever been hospitalized for a surgery, illness or accident?

15.Have you had any medical symptoms or pain in the last 90 days?

16.In the last 90 days have you visited the doctor for any treatments or made a program or plans for rehab or surgery?

17.In the last 90 days have you had any lab tests, x-rays, tomography, or ultra sounds done?

FOR WOMEN ONLY
18.Have you had any medical treatments or surgery related with your ovaries, uterus, or menstruation?

19.Have you been pregnant?

20. Did you have any problems or complications for your previous pregnancies?

21. Are you currently pregnant?

Dependant 2

1. Heart disease or hypertension (infarct, aneurysm, angina pectoris, atherosclerosis, other

2. Respiratory system disease (Tb, bronchitis, emphysema, asthma or sinusitis, other

3. Endocrine or metabolic disease (diabetes mellitus, thyroid, hypophysis or obesity

4. Blood disease (anemia or hemorrhage)

5. Circulatory system disease (varices, hemorrhoids, other)

6. Cancer or tumors

7. Any cerebral disease or nervous system disease (paralysis, convulsions, loss of conscience

8. Digestive system disease (esophagus, stomach, intestines, liver (hepatitis), biliary vesicle, pancreas, spleen, rectum, others

9. Urinary system disease (renal calculi, prostate enlargement, recurrent infections, other)

10. Auditory system alterations, skin problems, ophthalmological problems

11. Bone disease, joints, vertebral column, deformities, loss of a limb

12. Sexually transmitted disease, HIV, syphilis or human papillomavirus

13. Any illness or accident not specified on this medical questionnaire

14. Have you ever been hospitalized for a surgery, illness or accident?

15.Have you had any medical symptoms or pain in the last 90 days?

16.In the last 90 days have you visited the doctor for any treatments or made a program or plans for rehab or surgery?

17.In the last 90 days have you had any lab tests, x-rays, tomography, or ultra sounds done?

FOR WOMEN ONLY
18.Have you had any medical treatments or surgery related with your ovaries, uterus, or menstruation?

19.Have you been pregnant?

20. Did you have any problems or complications for your previous pregnancies?

21. Are you currently pregnant?

Dependant 3

1. Heart disease or hypertension (infarct, aneurysm, angina pectoris, atherosclerosis, other

2. Respiratory system disease (Tb, bronchitis, emphysema, asthma or sinusitis, other

3. Endocrine or metabolic disease (diabetes mellitus, thyroid, hypophysis or obesity

4. Blood disease (anemia or hemorrhage)

5. Circulatory system disease (varices, hemorrhoids, other)

6. Cancer or tumors

7. Any cerebral disease or nervous system disease (paralysis, convulsions, loss of conscience

8. Digestive system disease (esophagus, stomach, intestines, liver (hepatitis), biliary vesicle, pancreas, spleen, rectum, others

9. Urinary system disease (renal calculi, prostate enlargement, recurrent infections, other)

10. Auditory system alterations, skin problems, ophthalmological problems

11. Bone disease, joints, vertebral column, deformities, loss of a limb

12. Sexually transmitted disease, HIV, syphilis or human papillomavirus

13. Any illness or accident not specified on this medical questionnaire

14. Have you ever been hospitalized for a surgery, illness or accident?

15.Have you had any medical symptoms or pain in the last 90 days?

16.In the last 90 days have you visited the doctor for any treatments or made a program or plans for rehab or surgery?

17.In the last 90 days have you had any lab tests, x-rays, tomography, or ultra sounds done?

FOR WOMEN ONLY
18.Have you had any medical treatments or surgery related with your ovaries, uterus, or menstruation?

19.Have you been pregnant?

20. Did you have any problems or complications for your previous pregnancies?

21. Are you currently pregnant?

Dependant 4

1. Heart disease or hypertension (infarct, aneurysm, angina pectoris, atherosclerosis, other

2. Respiratory system disease (Tb, bronchitis, emphysema, asthma or sinusitis, other

3. Endocrine or metabolic disease (diabetes mellitus, thyroid, hypophysis or obesity

4. Blood disease (anemia or hemorrhage)

5. Circulatory system disease (varices, hemorrhoids, other)

6. Cancer or tumors

7. Any cerebral disease or nervous system disease (paralysis, convulsions, loss of conscience

8. Digestive system disease (esophagus, stomach, intestines, liver (hepatitis), biliary vesicle, pancreas, spleen, rectum, others

9. Urinary system disease (renal calculi, prostate enlargement, recurrent infections, other)

10. Auditory system alterations, skin problems, ophthalmological problems

11. Bone disease, joints, vertebral column, deformities, loss of a limb

12. Sexually transmitted disease, HIV, syphilis or human papillomavirus

13. Any illness or accident not specified on this medical questionnaire

14. Have you ever been hospitalized for a surgery, illness or accident?

15.Have you had any medical symptoms or pain in the last 90 days?

16.In the last 90 days have you visited the doctor for any treatments or made a program or plans for rehab or surgery?

17.In the last 90 days have you had any lab tests, x-rays, tomography, or ultra sounds done?

FOR WOMEN ONLY
18.Have you had any medical treatments or surgery related with your ovaries, uterus, or menstruation?

19.Have you been pregnant?

20. Did you have any problems or complications for your previous pregnancies?

21. Are you currently pregnant?

(*) If your answer is positive, please specify it on section 6 (Pre-Existing Conditions)

Mexican Health Insurance Application

1. Contracting Party Information *

2. Applicants *

Holder

Spouse or partner

Dependent 1

Dependent 2

Dependent 3

Dependent 4

3. Habits *

Holder

Spouse or partner

Dependent 1

Dependent 2

Dependent 3

Dependent 4

4. Other Activities *

Holder

Spouse or partner

Dependent 1

Dependent 2

Dependent 3

Dependent 4

5. Medical Questionnaire *

Holder

Spouse or partner

Dependant 1

Dependant 2

Dependant 3

Dependant 4

Puerto Vallarta

USA Affiliate