Membership Form Registration Membership Registration Form Thank you for connecting with us. We will respond to you shortly. 11https://aarpayment.aar-insurance.ug/wp-content/plugins/nex-formstrueredirecthttps://aarpayment.aar-insurance.ug/wp-admin/admin-ajax.phphttps://aarpayment.aar-insurance.ug/membership-form-registrationyes1fadeInfadeOut E-REGISTRATION MEMBERSHIP FORMPROSPECT NAMEMEMBER DETAILSSur Name: {{surname}}Other Name {{other_name}}*Date of Birth*Marital Status*Email AddressPhone Number: {{contact_number}} AllergiesGENDER--Select---MaleFemaleFirst Name: {{_name}}*Age Postal Address*OccupationHightWeightBlood GroupENTER BELOW DETAILS OF THE SPOUSE(01) AND DEPENDANTS WHERE APPLICABLESURNAME FIRST NAMEGENDER--Select---MaleFemaleDATE OF BIRTHALLERGIESCATEGORIES--Select---SpouseDependantSURNAME FIRST NAMEGENDER--Select---MaleFemaleDATE OF BIRTHALLERGIESCATEGORIES--Select---SpouseDependantSURNAME FIRST NAMEGENDER--Select---MaleFemaleDATE OF BIRTHALLERGIESCATEGORIES--Select---SpouseDependantSURNAME FIRST NAMEGENDER--Select---MaleFemaleDATE OF BIRTHALLERGIESCATEGORIES--Select---SpouseDependantMEDICAL DICLARATIONNOTE: FOR MEMBERSHIP TO BE CONSIDERED, THIS DECLARATION MUST BE COMPLETED IN FULL AND ALL QUESTIONS ANSWEREDIF THE ANSWER IS YES TO ANY OF THE QUESTIONS WHICH FOLLOW, KINDLY OBTAIN A MEDICAL REPORT FROM YOUR ATTENDING DOCTORS & ADDRESS OR FORWARD IT TOGETHER WITH YOUR APPLICATION FORM UNDER CONFIDENTIAL COVER TO THE UNDERWRITER OR EMAIL ADDRESS: underwriter.ug@aar-insurance.com WITHOUT WHICH YOUR APPLICATION MAY BE DELAYED.(a). CardiovascularHigh Blood PressureYes NoHeart DiseaseYes No(b). RespiratoryAsthmaYes NoTuberculosisYes No(c). EndocrineThyroid DiseaseYes NoDiabetesYes No(d). NeurologicalParalysisYes NoEpilepsyYes No(e). Musculo SkeletalArthritisYes NoGoutYes NoSlipped DiscYes No(f). Blood DisordersSickle Cell AnaemiaYes NoLeukaemiaYes NoHIV/AIDSYes No(g). Genito - UrinaryPelvic Inflammatory Disease (Female)Yes NoFibroids (Female)Yes NoEnlargement of the Prostate (Male)Yes No(h). Gastro - IntestinalDuodenal or Stomach UlcersYes NoLiver DiseaseYes NoPREVIOUS SURGICAL OPERATIONSYes NoOTHER MEDICAL CONDITIONS OR DISABILITIES(Not specifically covered)Yes No(k). Have you been hospitalised within the last 3 years?Yes NoIf yes give a reason(l). Are you on any regular prescribed medication?Yes NoIf yes (Type of medication)(m). Have you been screened or tested for any condition in the last three years?Yes No(Condition: Year: (Please attach copies of any records))(n). Are you a member of any rescue or medical insurance organization?Yes NoIf yes (Give details)(o). Have you had a pap smear (screening test for cervical cancer) in the last 1 year?Yes No(p). Have you had a PSA (screening test for prostate cancer) done?Yes No(q). Other than those declared above do you have any particularHealth concerns you wish to inform AAR about?Yes NoIf Yes (Give details)This is a signed declaration that this information is true and that AAR have the express authority to access any medical information from any source as required from time to time. I hereby consent to authorise AAR to receive/disclose to my employer any and all information, reports, records and or details relating to me including such medical or other information that would otherwise be confidential for the administration of the medical scheme Failure to disclose correct information will mean what may have been coverable becomes automatically excluded for both in-patient and out-patient cover*DATE OF SUBIMISSIONWho Introduced/ Encouraged/ Invited/ Inspired you to join AAR membership?AGENT/INTERMEDIARYAAR STAFF*Select Agent/Intermediary--- Select Name---JOY MBABAZIEDITH NYAKABWAAMINAH NALUBEGAROMEO OSCAR SERUWAGIPETER KIJARA KARUGABAAAR ORPHANRICHARD KAMYARITA KABIJAMU MUTUMBAREBECCA MUGAMBICUSTOMER SERVICE - BARAKASARAH MALWADDEFATUMAH NANKYAGRACE SSEBAGALA NAMPALACUSTOMER SERVICE - DIRECTCUSTOMER SERVICE - OBAMARICHARD TUSIIMEATURINDA VIANEYSAM OKUMAN ELANYUALEXANDER MAGEZI BINTAJONATHAN KATOGUMISIRIZA BENONMARTHA JOAN KASEKETEDDY SANYUOLIVIA NABASUMBAABDUL WAHAB NTWATWABRIAN MUTUNGIPADRE - PIOB. JUBILEE ALEXISBALLPACK INSURANCEROSHAN NANTEZAMILLY BASHEKA ATUHAIRENAMUTEBI VIVIANTUMWIJUKYE BENONWILLIS TOWERS WATSONKAMUKAMA JAMESOKORI DENNISNALUNKUUMA HILDAMINET LTDNYAKAHUMA ROBERTCUSTOMER SERVICE - PNEUMARUCAYA STEPHENCUSTOMER SERVICE - CRYSTALEVA KEMIREMBEMARSH UGANDAKEUBER INNOCENTAMPUMUZA JUDITHBUSIGU PAULIRANKUNDA RONALDEXIM BANK UGANDA LTDKAMULEGEYA ABDULNANNYONJO ANGELLA MKIIZA JOEL PAULAYEBALE BRINAHBUSOBOZI RONALDMUSIMENTA MOUREENOCTAGON UGANDA LTDBERNA ANGOM OFUNGIHILLCREST COMPANY LTDKINYERA KENNY ROGERSType Staff Name