Medical Insurance Application Form
1 APPLICANT’S DETAILS
Full Name: Date of Birth:
Gender: Marital Status:
Contact Number: Email Address:
Address:
PO Box: Visa Type: Partner Other
Employer: Emirate of issuing visa:
For Dubai visa holders only: Salary band: AED 4000 or below Above AED 4000
Applying to get insurance:
For myself (please proceed to section4) For myself and my dependents For my dependents only
2 DETAILS OF DEPENDENTS
Full Name Date of Birth Gender Relationship with the applicant
3 DETAILS OF UNDER ONE YEAR OLD CHILDREN (IF ANY)
Birth Weight: Birth Height:
Head Circumference: Delivery Status: Full-term Premature
Final Apgar Score:
No of weeks upon birth:
This is usually provided on baby’s medical card after delivery
Have the baby ever been diagnosed or received any treatment or felt any disorder or pain or had any symptoms for the following:
Asthma/Wheezes/Breathing Difficulty Yes No Cerebral Palsy Yes No
Cleft Palate Yes No Congenital Muscular Dystrophy Yes No
Congenital Liver Anomaly Yes No Congenital Heart Diseases Yes No
Congenital Lung Malformation Yes No Down Syndrome Yes No
Lymph node diseases Yes No Meningitis Yes No
Mass/Lumps Yes No Poor Eye control/Poor hearing Yes No
Skin Asthma/Rashes/Eczema Yes No Serious Infections Yes No
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Seizures/Convulsions/Neurological Ticks Yes No Undescended Testes Yes No
Other Physical Deformities Yes No Hydrocele/Genital Discharge Yes No
If other medical conditions with pending or on-going treatments other than the ones listed above exist, please specify:
Please list any prescription/ medications your child takes:
Please list any surgical procedure your child had:
4 MEDICAL BACKGROUND
Please indicate if any of those for whom you are applying for insurance, suffers from/experienced any of the following conditions:
Cancer Yes No Stroke Yes No
Heart Attack Yes No Kidney Failure Yes No
Organ Transplant Yes No Multiple Sclerosis Yes No
Paralysis Yes No Dismemberment Yes No
Aortic surgery Yes No Diseases of the respiratory system Yes No
Major Burns Yes No Benign Tumors Yes No
Parkinson’s disease Yes No Cystic Fibrosis Yes No
Diseases of blood/blood forming organs Yes No Congenital anomalies/hereditary diseases Yes No
Heart Valve Replacement Yes No Mental psychiatric disorder Yes No
Blindness, Deafness or Muteness Yes No Diseases of skin and subcutaneous tissue Yes No
Diseases of the cardiovascular system Yes No Diseases of the endocrine system Yes No
including hypertension including thyroid, diabetes
Diseases of the musculoskeletal system Yes No Any diseases, symptoms and conditions Yes No
and connective tissue not mentioned above
In case the answer is YES to any of the above, please specify below details for each condition:
Multiple copies of this section should be provided for each condition separately
Concerned applicant’s name:
Concerned condition:
Date of last treatment (If ongoing treatment, please indicate current date):
Diagnosis Status: Cured/No Symptoms Ongoing Symptoms Ongoing Hospitalization
Pending Hospitalization Ongoing Treatment Pending Treatment
Treatment type: Outpatient Hospitalized Both ways
If operated, please indicate its date:
Have any of the applicants ever had any bone fractures or injuries to bones or tendons? Yes No
If any material used for osteosynthesis, etc, have they been removed? Yes No
In case of diabetes, please specify whether the person is insulin dependent: Yes No
In case of cancer, please specify its stage:
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In case medication is required on a regular basis, please specify its genuine name, brand and daily/weekly quantity:
5 MATERNITY DECLARATION
Are any of the female applicants currently pregnant? Yes No
If Yes: Have there been any complications to date? Yes No
If not currently pregnant:
Is she undergoing any form of fertility treatment? Yes No
Is she currently trying to get pregnant? Yes No
When was her last menstrual period date:
6 EXISTING / PREVIOUS MEDICAL INSURANCE
Have you had medical insurance or currently have one? Yes No Its expiry date:
Has your spouse had medical insurance or currently has one? Yes No Its expiry date:
Have your children had medical insurance or currently have one? Yes No Its expiry date:
7 CONFIRMATION AND SIGNATURE
I agree that no indemnity will be paid under the proposed insurance policy for medical expenses arising from disorders 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 understand and acknowledge that any pregnancy not declared at the time of this application, its 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 that for 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 hereby agree, with this in respect to both, myself and my dependents that I am aware of the general terms of this insurance and I
accept them for myself and on behalf of my dependents. I, the undersigned declare that all of the above information are true and
complete. This information shall be considered as an integral part of the insurance policy.
Name: Date: Signature:
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