Individual/Family Medical Insurance Proposal Form     Please select the country/city where the form is to be submitted -Select Country- Kuwait Lebenon Saudi Arabia U.A.E 1 Name of the Proposer 2 Postal Address 3 Telephone No 4 Fax No 5 E-mail 5 Country of Residence -Select a Country- Afghanistan Albania Algeria American Samoa Andorra Angola Anguilla Antarctica Antigua and Barbuda Argentina Armenia Aruba Australia Austria Azerbaijan Bahamas Bahrain Bangladesh Barbados Belarus Belgium Belize Benin Bermuda Bhutan Bolivia Bosnia and Herzegovina Botswana Bouvet Island Brazil British Indian Ocean Territory Brunei Darussalam Bulgaria Burkina Faso Burma Burundi Cambodia Cameroon Canada Canton and Enderbury Islands Cape Verde Cayman Islands Central African Republic Chad Chile China Christmas Island Cocos (Keeling) Islands Colombia Comoros Congo Cook Islands Costa Rica Cote D'Ivoire Croatia (Hrvatska) Cuba Cyprus Czech Republic Democratic Yemen Denmark Djibouti Dominica Dominican Republic Dronning Maud Land East Timor Ecuador Egypt El Salvador Equatorial Guinea Eritrea Estonia Ethiopia Falkland Islands (Malvinas) Faroe Islands Fiji Finland France France, Metropolitan French Guiana French Polynesia French Southern Territories Gabon Gambia Georgia Germany Ghana Gibraltar Greece Greenland Grenada Guadeloupe Guam Guatemala Guinea Guinea-bisseu Guyana Haiti Heard and Mc Donald Islands Honduras Hong Kong Hungary Iceland India Indonesia Iran (Islamic Republic of) Iraq Ireland Israel Italy Ivory Coast Jamaica Japan Johnston Island Jordan Kazakstan Kenya Kiribati Korea Democratic People's Republic Korea, Republic Kuwait Kyrgyzstan Lao People's Democratic Republic Latvia Lebanon Lesotho Liberia Libyan Arab Jamahiriya Liechtenstein Lithuania Luxembourg Macau Macedonia Madagascar Malawi Malaysia Maldives Mali Malta Marshall Islands Martinique Mauritania Mauritius Mayotte Mexico Micronesia, Federated States Midway Islands Moldova, Republic Monaco Mongolia Montserrat Morocco Mozambique Myanmar Namibia Nauru Nepal Netherlands Netherlands Antilles Neutral Zone New Calidonia New Zealand Nicaragua Niger Nigeria Niue Norfolk Island Northern Mariana Islands Norway Oman Pacific Islands Pakistan Palau Panama Papua New Guinea Paraguay Peru Philippines Pitcairn Island Poland Portugal Puerto Rico Qatar Reunion Romania Russian Federation Rwanda S. Georgia and S. Sandwich Isls. Saint Lucia Saint Vincent/Grenadines Samoa San Marino Sao Tome and Principe Saudi Arabia Senegal Seychelles Sierra Leone Singapore Slovakia (Slovak Republic) Slovenia Solomon Islands Somalia South Africa Spain Sri Lanka St. Helena St. Kitts Nevis Anguilla St. Pierre and Miquelon Sudan Suriname Svalbard and Jan Mayen Islands Swaziland Sweden Switzerland Syran Arab Republic Taiwan Tajikistan Tanzania Thailand Togo Tokelau Tonga Trinidad and Tobago Tunisia Turkey Turkmenistan Turks and Caicos Islands Tuvalu US Minor Outlying Islands Uganda Ukraine United Arab Emirates United Kingdom United States United States Pacific Islands Upper Volta Uruguay Uzbekistan Vanuatu Vatican City State Venezuela VietNam Virgin Islands, British Virgin Islands, Unites States Wake Island Wallis and Futuma Islands Western Sahara Yemen Yugoslavia Zaire Zambia Zimbabwe 6 Country of Origin/Nationality -Select a Country- Afghanistan Albania Algeria American Samoa Andorra Angola Anguilla Antarctica Antigua and Barbuda Argentina Armenia Aruba Australia Austria Azerbaijan Bahamas Bahrain Bangladesh Barbados Belarus Belgium Belize Benin Bermuda Bhutan Bolivia Bosnia and Herzegovina Botswana Bouvet Island Brazil British Indian Ocean Territory Brunei Darussalam Bulgaria Burkina Faso Burma Burundi Cambodia Cameroon Canada Canton and Enderbury Islands Cape Verde Cayman Islands Central African Republic Chad Chile China Christmas Island Cocos (Keeling) Islands Colombia Comoros Congo Cook Islands Costa Rica Cote D'Ivoire Croatia (Hrvatska) Cuba Cyprus Czech Republic Democratic Yemen Denmark Djibouti Dominica Dominican Republic Dronning Maud Land East Timor Ecuador Egypt El Salvador Equatorial Guinea Eritrea Estonia Ethiopia Falkland Islands (Malvinas) Faroe Islands Fiji Finland France France, Metropolitan French Guiana French Polynesia French Southern Territories Gabon Gambia Georgia Germany Ghana Gibraltar Greece Greenland Grenada Guadeloupe Guam Guatemala Guinea Guinea-bisseu Guyana Haiti Heard and Mc Donald Islands Honduras Hong Kong Hungary Iceland India Indonesia Iran (Islamic Republic of) Iraq Ireland Israel Italy Ivory Coast Jamaica Japan Johnston Island Jordan Kazakstan Kenya Kiribati Korea Democratic People's Republic Korea, Republic Kuwait Kyrgyzstan Lao People's Democratic Republic Latvia Lebanon Lesotho Liberia Libyan Arab Jamahiriya Liechtenstein Lithuania Luxembourg Macau Macedonia Madagascar Malawi Malaysia Maldives Mali Malta Marshall Islands Martinique Mauritania Mauritius Mayotte Mexico Micronesia, Federated States Midway Islands Moldova, Republic Monaco Mongolia Montserrat Morocco Mozambique Myanmar Namibia Nauru Nepal Netherlands Netherlands Antilles Neutral Zone New Calidonia New Zealand Nicaragua Niger Nigeria Niue Norfolk Island Northern Mariana Islands Norway Oman Pacific Islands Pakistan Palau Panama Papua New Guinea Paraguay Peru Philippines Pitcairn Island Poland Portugal Puerto Rico Qatar Reunion Romania Russian Federation Rwanda S. Georgia and S. Sandwich Isls. Saint Lucia Saint Vincent/Grenadines Samoa San Marino Sao Tome and Principe Saudi Arabia Senegal Seychelles Sierra Leone Singapore Slovakia (Slovak Republic) Slovenia Solomon Islands Somalia South Africa Spain Sri Lanka St. Helena St. Kitts Nevis Anguilla St. Pierre and Miquelon Sudan Suriname Svalbard and Jan Mayen Islands Swaziland Sweden Switzerland Syran Arab Republic Taiwan Tajikistan Tanzania Thailand Togo Tokelau Tonga Trinidad and Tobago Tunisia Turkey Turkmenistan Turks and Caicos Islands Tuvalu US Minor Outlying Islands Uganda Ukraine United Arab Emirates United Kingdom United States United States Pacific Islands Upper Volta Uruguay Uzbekistan Vanuatu Vatican City State Venezuela VietNam Virgin Islands, British Virgin Islands, Unites States Wake Island Wallis and Futuma Islands Western Sahara Yemen Yugoslavia Zaire Zambia Zimbabwe 7 Proposer's Occupation 8 Proposer's Date of Birth 9 Citizenship 10 Sex -select- Male Female Details of the Dependents (Family/Individual Proposal Form) Dependents Family/ Surname First Name with Initials Relationship with the Proposer(Spouse/son/Daughter/ Mother/Fathers/Others) Sex Date of Birth 1 -select- Female Male 2 -select- Female Male 3 -select- Female Male 4 -select- Female Male 5 -select- Female Male 6 -select- Female Male 7 -select- Female Male  Note: For more than 7 numbers, please use one more proposal form. Medical History (Declaration made herein forms the basis of acceptance. It is essential to correctly disclose all relevant information. Any non-disclosure could affect the reimbursement of benefits in the event of a claim.)   No of Dependents 1 2 3 4 5 6 7 1. General Practitioner's Treatment a) G.P. consultation during the last 2 years select Yes No select Yes No select Yes No select Yes No select Yes No select Yes No select Yes No b) How many times? c) Present State of Health select Good Average Bad select Good Average Bad select Good Average Bad select Good Average Bad select Good Average Bad select Good Average Bad select Good Average Bad d) Will same treatment be required in near future? select Yes No select Yes No select Yes No select Yes No select Yes No select Yes No select Yes No 2. . Specialist Treatment: a) Specialist consultation during last 2 Years select Yes No select Yes No select Yes No select Yes No select Yes No select Yes No select Yes No b) How many times? c) Illness / Medical Condition d) Present State of Health select Good Average Bad select Good Average Bad select Good Average Bad select Good Average Bad select Good Average Bad select Good Average Bad select Good Average Bad e) Will same treatment be required in near future? select Yes No select Yes No select Yes No select Yes No select Yes No select Yes No select Yes No 3. Hospitalization (In-Patient) a) Hospitalization during last 2 Yrs select Yes No select Yes No select Yes No select Yes No select Yes No select Yes No select Yes No b) How many times? c) Total No. of days d) Illness / Medical Condition e) Present State of Health select Good Average Bad select Good Average Bad select Good Average Bad select Good Average Bad select Good Average Bad select Good Average Bad select Good Average Bad f) Will same treatment be required in near future? select Yes No select Yes No select Yes No select Yes No select Yes No select Yes No select Yes No 4. General Particulars a) Does any of the dependent have any congential or other deformity? select Yes No select Yes No select Yes No select Yes No select Yes No select Yes No select Yes No b) Description of the deformity c) Does any of the dependent suffer from any chronic disease? select Yes No select Yes No select Yes No select Yes No select Yes No select Yes No select Yes No d) Does any of the dependent engage in any hazardous sports or activities? select Yes No select Yes No select Yes No select Yes No select Yes No select Yes No select Yes No Benefits required (a) In Patient Treatment only. (b) Out Patient Treatment only. (c) In & Out Patient Treatment. Limits required: (Per person per year) (a) Dhs.50,000 (b) Dhs. 100,000 (c) Dhs. 200,000 (d) Dhs. 300,000 (e) Dhs. 500,000 Geographical Area required: (a) U.A.E Only (b) UAE+ARAB COUNTRIES+SOUTH EAST ASIA (c) WORLDWIDE excluding USA and CANADA Room and Board limit: Dhs per day. Pre-Existing Conditions: (a) To be deleted. (b) 30 days waiting period (c) 60 days waiting period (d) 90 days waiting period (e) 180 days waiting period Deductible/Excess Dhs. per person per claim. Additional Optional Covers: (a) Maternity (b) Dental (c) Optical (d) Repatriation [ To download the form please right click the Download button and select "Save target as" and Save.]  Download the Form              Download Acrobat Reader Top