Bioanthropology Research Institute, Quinnipiac University
NAME IN FULL
PNG MUMMY RESEARCH
NO. OF DAYS/WEEKS ON PROJECT:
It is mandatory that you answer the following:
2. Height_Weight _
3. Have you, to the best of your knowledge and belief, ever had or have reasons to know you had:
A. Convulsions, paralysis or stroke, fainting attacks, □ □ severe headaches, or disease of the brain or nervous system?
B. High blood pressure, heart attack, pain in chest, angina EH I I pectoris, or any other disorder of the heart or blood vessels?
C. Tuberculosis, asthma, emphysema, persistent cough, or □ □ any other disease or abnormality of the lungs or respiratory system?
D. Duodenal or gastric ulcer, colitis, or any other disease □ □ or abnormality of the stomach, intestines, rectum, liver, pancreas, gall bladder, or hernia?
E. Sugar, albumin, blood or pus in urine, kidney stones, EH EH or any other disorder of the bladder, kidney, or genitourinary system?
F. Diabetes, gout, or any disease or abnormality of the EH EH thyroid or other glands?
G. Any disease, disorder or injury of the bones, joints, □ □ muscles, back, spine, or neck?
* See Chapter 10 for description.
H. In the past five years, cold sores on lips or face?
I. In the past year, any significant change in weight? J. Been treated for or had indication of excessive use of alcohol or drugs? K. Disorder of skin, lymph glands, cyst, tumor, or cancer?
L. Disorder of eyes, ears, nose, or throat? M. Allergies, anemia, or other disorder of the blood?
4. Have you ever used LSD, heroin, cocaine, or any other narcotic, depressant, stimulant, or psychedelic, whether prescribed or not prescribed by a doctor?
5. During the last 21 days, have you been exposed to any infection or contagious disease?
6. Have you consulted a doctor, been under a doctor's care, had surgical advice or treatment, or been confined to a hospital during the past five years?
7. Have you, within the past three years, been disabled as a result of any illness while working in any film or stage production?
8. Are you now, or will you at any time during the period of this production, be taking part in any other film or stage production or other professional engagement?
9. Are you now (or in the past 30 days) taking any medication or health treatments?
10. Do you suffer from any phobias, or are you aware of any mental health problems that may prevent you from carrying out your scheduled production activities?
11. Has any insurance company declined to insure you or imposed any special terms in regard to your acceptance for any Cast Insurance; Non-Appearance Insurance; or Accident, Health, or Life Insurance?
A. Are you pregnant? YES_NO_If so, how many months?_
B. Have you ever had any disease of the breasts, uterus, tubes, or ovaries? YES_NO_If yes, give full details:_
For "yes" answers, state details fully here, that is, diagnosis, treatment, results, dates of disability, degree of recovery, name and address of attending doctor, etc.:_
13. If under age 9, please advise what childhood diseases you have had, and attach a copy of your immunization record_
14. (A) When did you last receive a complete physical examination?
(B) What were the results?
(C) Name and address of doctor:
15. To the best of your knowledge and belief, are you now in good health and free from physical impairment or disease? YES_NO_
If "no," give full details:_
I declare and affirm that I am the person first named above; that the statements made hereon by me are true, correct, and complete; that I have withheld no information known to me which might alter or otherwise conflict with the statements made by me. I understand that an insurance policy may be issued based on the statements made hereon by me. If a policy is issued and a claim is paid thereunder I understand that the insurer will seek recoupment from me if it is thereafter determined that the statements I made hereon are not true, correct, and otherwise complete, or that I have withheld information known to me which might alter or otherwise conflict with the statements I have made, the insurer will hold me personally liable and will seek recoupment from me for such payment. I also agree to be reexamined by the insurer's doctors in the event a claim is made.
I authorize any doctor, licensed practitioner, hospital, clinic, other medical or medically related facility, or insurance or reinsuring company having information available as to diagnosis, treatment, and prognosis with respect to any physical or mental condition and/ or treatment of me to give to XXXX Insurance Company of Europe , or its legal representative, any and all such information.
I understand the information will be used by the Underwriting and Claims departments of XXXX Insurance Company of Europe for underwriting and claim settlement purposes.
I know that I may request a copy of this authorization.
I agree that this authorization shall be valid for a period of two years from the date on which it was signed.
WITNESS TO SIGNATURE
N.B. FAILURE TO FULLY COMPLETE THIS FORM, INCLUDING SIGNATURE AND WITNESS SECTIONS, COULD CAUSE DELAY IN APPROVAL THEREOF.
FOR INSURANCE COMPANY USE ONLY
_Accepted for accident only
_Accepted subject to the following:
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