Individual & Family Health Insurance Proposal Form & Medical Questionnaires

Page 1 of 6

M E M B E R D E T A I L S

Full Name:

Address:

Nationality: Marital Status:

Employer: Occupation:

Mobile No.

Email:

Office Phone:

Name of Plan Selected

Fax Number:

M E M B E R A N D D E P E N D E N T I N F O R M A T I O N

Principal Spouse Child 1 Child 2 Child 3

First Name

Middle Name

Family Name

Gender

Date of Birth

Height (cms)

Weight(kg)

Emirates ID Number

Previously Insured?

If Yes, please provide details, where and how long.

Individual & Family Health Insurance Proposal Form & Medical Questionnaires

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PRINCIPAL YES NO

SPOUSE YES NO

CHILD 1 YES NO

CHILD 2 YES NO

CHILD 3 YES NO

Please answer the following questions for all named applicants. (Please tick the relevant box).

Questions

1 Are you in good health and free from any deformity or defect?

2 Have you ever been declined for health and/or life insurance?

3 Have you ever been accepted for health and/or life insurance on sub- standard terms?

4 Do you involve yourself in any dangerous sporting activities or ride a motorcycle?

5 Are you pregnant now? If Yes, when do you expect to deliver?

6 Musculoskeletal &/or Connective Tissue System i.e. fracture, joint or carti lage problems, back bone infections, osteoporosis, arthriti s, rheumatism, etc)

7 Neoplasm , Cancer, Tumors (Specify type, location, treatment, whether malignant or benign)

8 Blood & Blood Forming Organs System (i.e. anemia, thalassemia, bleeding disorders, blood cell, lymph node problems etc.)

9 Digestive System (i.e. reflux, ulcers, diverticulI, bleeding-infection-obstruction- perforation or problems of the teeth/gum/ mouth/ jaw, liver problem, gall bladder or pancreas, anal / rectal polyps etc.

10 Endocrine, Nutritional, Metabolic and/or immunity System ( i.e. diabetes, thyroid or pituitary or testes problems, hormone problems, gout, multiple sclerosis, cystic fibrosis, metabolic disorders, etc.

11

Nervous System or Sense Organs (i.e. ear injury/infection, vertigo, hearing problems, eye vision problems, muscular dystrophy, brain/nerve degeneration, meningiti s, paralysis, seizures, etc.

12

Genitourinary System ( i.e. kidney/ bladder infections, renal failure, kidney stones, salpingitis, ovarian cysts, prostate problems, impotence, testicle infections, sperm abnormalities, breast disorders, etc.

Individual & Family Health Insurance Proposal Form & Medical Questionnaires

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PRINCIPAL YES NO

SPOUSE YES NO

CHILD 1 YES NO

CHILD 2 YES NO

CHILD 3 YES NO

SN

QUESTIONS

13 Respiratory System (i.e. sinusitis, allergi es, tonsillitis/laryngiti s, bronchitis, emphysema, etc.

14 Cardiovascular System (i.e. stroke, cerebral i schemia, rheumati c fever arthrosclerosis, ischemic heart disease, hypertension, heart valve disease, irregular heart beat, pulmonary embolism, phlebiti s, etc.

15

Skin Subcutaneous Tissue (i.e. dermatitis, acne, seborrhea, purities, etc.)

16

Pregnancy, complication of pregnancy, child birth and the puerperium

17 Mental Disorders

18

Infectious and parasi tic diseases

19 Congenital anomalies, hereditary diseases 20 Injury and poisoning

21 Previous medical / surgical hospitali zation, procedures and operations (if any)

22

Have you ever been tested posi tive for HIV (AIDS) and for other infectious diseases (e.g. Hepati ti s) or Have any medical condition or symptoms indicative of HIV infection or AIDS?

23 Any diseases, symptoms and complaints not mentioned above

24 Do you smoke? If yes, please mention number per day.

25 Any family member for whom insurance is not applied in this application. (If yes, please provide particulars of existing insurance arrangements).

26 Have you ever undergone surgery to remove a body organ or structure? ( if yes, specify body organ/structure with date and place of surgery)

Individual & Family Health Insurance Proposal Form & Medical Questionnaires

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Inherited disorder or genetic disease Cancer Muscular Dystrophy Diabetes Hemophilia Multiple Sclerosis Nervous System / Sense Organ Disease Illness of Cardiovascular System Mental Illness or Disorder Inherited disorder or genetic disease

In case the answer is YES to any of the conditions/diseases above, please specify full details below.

Answers to Questions (if answered as Yes)

Principal Spouse Child 1 Child 2 Child 3

Family Medical History (Father, Mother, Siblings) Have any member of your family had symptoms or been diagnosed or received treatment with respect to conditions li sted in the side box?

Chronic Diseases:

A disease with one or more of the following characteristics: lasts 3 months or more, leaves residual disability, is caused by non-reversible pathological alteration, requi res special training of the patient for rehabilitation, or may require a long period of supervision, observation, or case.

Date:

(Signature over Printed Name) PRINCIPAL

Individual & Family Health Insurance Proposal Form & Medical Questionnaires

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DECLARATION:

I/We hereby declare with respect to both, myself and my dependants that to the best of my knowledge and belief, the statement on application are full, true and correct and have declared all material facts related to this application.

I/We understand that non-disclosure or misrepresentation of any material fact may invalidate the quoted terms. I/We agree that all the documents issued in connection with the policy shall be read together.

If my application gets accepted, I/We agree to be bound by the terms and conditions of the policy. I/We hereby authorize any doctor, Hospital ,Clinic or Medical Provider, any Insurance Company or any other Company, institution or any other person who has any record or information about me and/or any of my family members to provider Dubai National Insurance Company, with the complete information, including copies of their records with reference to any sickness or accident, any treatment, examination, advice or hospitalization or any other medical information required by Dubai National Insurance Company..

The Coverage of Health Services provided by Dubai National Insurance Company is described in the policy wording. By signing this for, I/We acknowledge that I/We read, understood and agree to the terms and conditions as stated in the policy wording.

I/We agree that after acceptance of the quoted premiums in the quotation, I/We shall be liable to pay all the premiums to Dubai National Insurance Company as per the specified and selected plan of our choice.

Dubai National Insurance Company reserves the right to reject any authorization/claims request for conditions (pre- existing, chronic) not declared by the applicant at the inception of the policy.

Date:

Signature over Printed Name

Individual & Family Health Insurance Proposal Form & Medical Questionnaires

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PRE-EXISTING DECLARATION FORM

I hereby understand and acknowledge that this plan will not cover any expenses

(consultation/tests/related conditions) until expiry of the policy, in respect to pre-existing

conditions that are not declared while at the initial purchase of insurance i.e. as at starting

from the enrolment date as per the following contract wording definition;

Pre-Existing Condition: Any Beneficiary health condition known and/or unknown to the

Beneficiary and/or to the Contract holder that may or may not have exhibited symptoms or

was a consequence of Injury or Illness for which medical, Surgical and/or pharmaceutical

Treatment, medical diagnosis or other advice was provided prior to the Beneficiarys

Enrollment Date.

I hereby relieve DNIRC from any liability related to this Clause.

Date:

Signature over Printed Name