Membership Form

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Benefit (please tick)
Cosmo Classic
Cosmo Essential
Cosmo Premium
Cosmo Premium Plus
Medical History (Select Applicable Conditions)
Allergies
Anemia
Angina
Asthma
Back Neck Joint Problems
Benign cancer
Bladder Infections
Chronic Bronchitis
Congenital Heart Abnormalities
Congenital kidney disorder
Cystic Fibrosis
Depression or Psychiatric disorder
Diabetes Mellitus
Disorder of the digestive system
Embolism
Emphysema
Endocrine disorder
Epilepsy
Fibroid
Gall bladder disease
Gout
Heart attack
Heart disease
Hepatitis
High Blood Pressure
High Cholesterol Level
Intestinal Fibrosis
Kidney stone
Leukemia
Life insurance rejected
Liver condition
Lung disease
Malaise
Malignant cancer
Migraine
Nephritis
Pregnancy
Rheumatic Arthritis
Rheumatic Fever
Severe recurrent diarrhoea
Smoking
Spectacles or contact lenses
Stroke
Thrombosis
Thyroid disorder
Tuberculosis
Ulcers
Varicose Veins
Other

Dependants

Dependant Medical History (Select Applicable Conditions)
Allergies
Anemia
Angina
Asthma
Back Neck Joint Problems
Benign cancer
Bladder Infections
Chronic Bronchitis
Congenital Heart Abnormalities
Congenital kidney disorder
Cystic Fibrosis
Depression or Psychiatric disorder
Diabetes Mellitus
Disorder of the digestive system
Embolism
Emphysema
Endocrine disorder
Epilepsy
Fibroid
Gall bladder disease
Gout
Heart attack
Heart disease
Hepatitis
High Blood Pressure
High Cholesterol Level
Intestinal Fibrosis
Kidney stone
Leukemia
Life insurance rejected
Liver condition
Lung disease
Malaise
Malignant cancer
Migraine
Nephritis
Pregnancy
Rheumatic Arthritis
Rheumatic Fever
Severe recurrent diarrhoea
Smoking
Spectacles or contact lenses
Stroke
Thrombosis
Thyroid disorder
Tuberculosis
Ulcers
Varicose Veins
Other

Declaration

I hereby declare that the information provided is true to the best of my knowledge.

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