MAJIF TRUST Registration

Please fill out this registration form to apply for membership.

An answer must be given to all question.
You may use the label “Additional info” to supply any other information relating to your professional status.
Please select the appropriate box, “YES/NO” as applicable.
This application will be considered incomplete unless all questions are answered. Completing the form does not bind the applicant or MAJIF TRUST to complete the insurance.

MAJIF TRUST Registration Form

Basic Information

Speciality:

Do you have sub-specialties?

Application Type
NewReinstatement

Lapsed policy will attact 40% on basic premium

First Name

Middle Name

Last Name

Date of Birth:

Email Address

Address of Practice

Mailing Address

Sex
MaleFemale

Telephone

Work

Home

Cell

Practice Information

Year Of Graduation

Number of Years in Practice

Name of Medical School

Address of Medical School

Internship Information

Internship(1)
Date

Place

Add More Internships

Internship(2)
Date

Place

Internship(3)
Date

Place

Post Internship Information

Internship(1)
Date

Place

Duty

Add More Post Internships

Internship(2)
Date

Place

Duty

Internship(3)
Date

Place

Duty

Registration Information

Kindly state your Governing Body Eg. Medical Council of Jamaica, Nursing Council of Jamaica etc.

Registration Number

Expiry Date

Sub Speciality

Primary Hospital Affiliation

Rate Calculation

Indicate the amount of coverage required:

Group (based on specialty and sub-specialty chosen)

Basic Premium

Do you practice overseas? If yes please select the country:

Overseas coverage adds 25% to your premium.

Do you practice any of the following?

Laser surgery adds 15% to your premium.

Laproscopic surgery adds 20% to your premium.

Health tourism adds 100% to your premium.

Proposed commencement date of policy:

Is this a new policy or renewal?

New policy
Renewal / Reinstatement

Is your policy lapsed?
Yes
No

A lapsed policy adds 40% to your basic premium.

Payment type

Total Premium

First Installment

Additional Installments

Additional

I HEREBY DECLARE: that the above statement and particulars are true and that I have not suppressed or misstated any material facts and I agree that this Proposal Form and any supplementary information sheet(s) attached hereto shall be the basis of the contract with the MAJIF TRUST.

I agree