Medical Application Form: Insured Name: Inception Date

Medical Application Form
Insured Name: Inception Date:
Required Plan: Policy No.:
NAME please specify Employee (E), Child (C) or Spouse Nationality

(S) Relation D. O. B. Sex Height Weight Blood UAE
Resident
First Name Middle Name Family Name E / S / C DD/MM/YYYY M/F CM KG TYPE
No
Is there a member in your family that is not proposed for Insurance? Yes If Yes, please explain under section
Comments
Marital Status: No. of Children: Active at work since:

Street: City: P.O. Box: Tel. No:
Have you ever been diagnosed or received any treatment (including hospital or surgery) or felt any disorder or pain or had any symptoms
indicating:
(Please tick relevant box) Yes No Yes No

1. Infectious and parasitic diseases 10. Diseases of genitourinary system, kidney diseases and
breast disorders
2. Neoplasms/Cancer (benign or malignant) 11. Pregnancy, complications of pregnancy, child birth and
the puerperium incl. abortions
3. Diseases of the endocrine system, nutritional-, 12. Disease of the skin and subcutaneous tissue
metabolic diseases and immunity disorders, diabetes
4. Diseases of blood and blood forming organs 13. Diseases of the musculoskeletal system and connective
tissue
5. Mental-/psychiatric disorders 14. Congenital anomalies, hereditary/genetic diseases
6. Diseases of the nervous system and sense organs (ears, 15. Certain conditions originating in the perinatal period
eyes, nose)
7. Diseases of the cardiovascular system 16. Injury and poisoning

incl. hypertension
8. Diseases of the respiratory system 17. Previous medical/surgical hospitalizations, procedures

and operations
9. Diseases of digestive system 18. Any (chronic) disease(s), symptoms and complaints not
mentioned above
In case the answer is YES to any of the conditions/diseases above please specify full details (preferably by a Medical Physician)
on the additional questionnaire (Personal Information), which will be found attached to this application form.
In case medication is required on a regular basis please specify the full details such as genuine name, brand name and
daily/weekly quantity on the additional questionnaire (Personal Information), which will be found attached to this application form.
Comments: Only to be filled out, if you have answered, “Yes” in the question of any family members, who is not proposed for
Insurance.
Refund Premium:
Yes No
for cancelation/deletion requests, do you want the refund premium to be paid to your company?
If yes, please mention the company name and the cheque will be issued in the mentioned name
For Married females:

Yes No
- Are you currently pregnant? If yes, have there been any complications to date?
- Last Menstrual period date:
- Are you currently trying to get pregnant?
- Are you undergoing any form of fertility treatment?
I understand and acknowledge any pregnancy not declared at the time of this application’s coverage will be at the sole discretion of
the insurer. The insurer has the right to not cover any maternity claims to any undeclared pregnancy. I also acknowledge and
understand any pregnancy, which arises within forty calendar days from the date of this application; coverage will also be at the
discretion of the insurer.
I agree that no indemnity will be paid under the proposed insurance policy for medical expenses arising from disorders which were
declared prior to completion of this Application and which were not disclosed to the insurer at the date of this application. Failure to
disclose material information to the insurer will invalidate the proposed insurance policy.
I hereby declare and agree, with respect to both, myself and to my Dependents, that I am aware of the general terms of this insurance
and I accept them. With the above, I authorize my doctor, health institution or other organization or person that has any information
about my health and/or activities (and those of my Dependents) to provide the Insurer with the said information. This shall include
hospital and any other records pertaining to medical advice, diagnosis, treatment or disturbances. A photocopy of this authorization
has the same validity as the original. I the undersigned declare that all of the above information as well as all declarations on the
additional questionnaire (personal information) are true and complete. This information shall be considered as an integral part of the
insurance policy.
Date:
Signature:
Medical Conditions
Name of applicant Age: Sex:
Date of application: / / (dd/mm/yyyy)
Medical condition/diagnosis:
(if more than one sickness, please complete a separate form for each)
Date of last treatment/symptoms: / / (dd/mm/yyyy) ongoing treatment = current date
Diagnosis Status: Yes No

• Cured/ no symptoms
• Ongoing symptoms
• Ongoing hospitalization
• Pending hospitalization
• Ongoing treatment Pending treatment
In case of any Diagnosis Status the applicant was treated as:

• Outpatient
• Hospitalized
• Treated both ways
• Operated on: / / (dd/mm/yyyy)
How often do the symptoms occur?

Or can the illness be described as follows?
• Acute
• Chronic Recurrent
Did you have any bone fractures or injuries to bones or tendons?

Has any material used for osteosynthesis etc. been removed?
In case medication is required on a regular basis please specify the genuine name, The brand name as well as the
daily/weekly quantity below.
In case you are suffering from hypertension please specify your Systolic and Diastolic readings below.
Systolic:
Diastolic:
In case of diabetes please specify whether insulin dependent.
Date:
Signature:

Medical Application Form: Insured Name: Inception Date

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Medical Application Form: Insured Name: Inception Date

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Medical Application Form

Insured Name: Inception Date:

Required Plan: Policy No.:

NAME please specify Employee (E), Child (C) or Spouse Nationality

Marital Status: No. of Children: Active at work since:

(Please tick relevant box) Yes No Yes No

5. Mental-/psychiatric disorders 14. Congenital anomalies, hereditary/genetic diseases

7. Diseases of the cardiovascular system 16. Injury and poisoning

8. Diseases of the respiratory system 17. Previous medical/surgical hospitalizations, procedures

For Married females:

Name of applicant Age: Sex:

Date of application: / / (dd/mm/yyyy)

Date of last treatment/symptoms: / / (dd/mm/yyyy) ongoing treatment = current date

Diagnosis Status: Yes No

In case of any Diagnosis Status the applicant was treated as:

How often do the symptoms occur?

Did you have any bone fractures or injuries to bones or tendons?

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