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Application For New Membership
-New Member to Complete this Form
-Read Terms and Conditions
-Where Applicable Put N/A
Gender *


*Please note: cover is subject to acceptance by General & Medical and payment of the appropriate premium. Whilst we will try to begin cover on the date indicated it cannot be guaranteed. There may be some circumstances where we have agreed to hold cover but you should note that we will not back date applications/cover.



List of Dependents




1. The general waiting period for accessing basic medical care is 3 months.
2. Maternity: 9 months waiting period applies to all new policies. However, in the relationship of husband and wife, where the husband's policy had been running for a period of more than 9 months, the 9 months waiting period shall not be applied to the wife’s policy. In such cases the wife only has to wait for 3 months before she can access benefits under her policy.
3. 12 months initial waiting period shall be applied to optical costs (lenses, glasses frames and other associated costs) and 3 year waiting period shall apply thereafter.
4. 6 months waiting period shall apply for dental care.
5. 12 months waiting period shall apply for all foreign specialist care.
6. The Starter product covers in-patient costs only. However, policy holders under this plan will be allowed access to network doctors (GPs).
7. The maximum of 12 visits per annum shall be allowable for specialist consultants for all policies.
8. Pre-existing conditions: policy holders shall not be denied cover because of pre-existing medical conditions. However, a period shall be imposed on all the pre-existing medical conditions.


1. The period of cover will end upon the occurrence of either one of the following events:
(a) At the end of the academic year
(b) Upon termination of the studies by either the student or the university
(c) Termination of contract of cover between the university and Ultra-Med Health Care, whichever is to occur first.
2. Start date is effective at the first day of the semester and runs until the last day of the 6 months after inception
3. Declaration of Medical History –students will be required to declare the medical history. Such information will not be used
to deny the student cover, but will help the Fund to make arrangements for suitable health and care facilities for the student.
Ultra-Med will not cover the following:
(a) Injuries/sickness/ disability arising from attempted suicide
(b) Sickness arising from drug addiction
and abuse of addictive substances
(c) Sickness/disability from participation in illegal activities
(d) Policy holders that fail to disclose material information or misrepresent information
(e) Fraudulent claims.

List of Pre-existing Conditions


My Declaration *
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