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This document contains a health declaration form for an individual applying for group medical insurance. It asks questions about the applicant's medical history and current health status. The applicant, Priyanga, affirms that she does not have any existing medical conditions by answering "No" to all questions. She confirms her marital status as married, but indicates no pregnancy or gynecological issues. The form collects her personal details and health information to assess eligibility for the insurance plan.

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Saravana Kumar
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Download as PDF, TXT or read online on Scribd
17 views

HD Format

This document contains a health declaration form for an individual applying for group medical insurance. It asks questions about the applicant's medical history and current health status. The applicant, Priyanga, affirms that she does not have any existing medical conditions by answering "No" to all questions. She confirms her marital status as married, but indicates no pregnancy or gynecological issues. The form collects her personal details and health information to assess eligibility for the insurance plan.

Uploaded by

Saravana Kumar
Copyright
© © All Rights Reserved
Available Formats
Download as PDF, TXT or read online on Scribd
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HEALTH DECLARATION - GROUP MEDICAL INSURANCE SCHEME

Name of Employer & Policy Number

Name of employee/ life assured. Priyanga

Date of Birth 14/10/1991 Dept. /Designation Housewife

Passport No: L3673298 Emirates ID No: 784-1991-9715355-6 Visa Location: Ras Al Khaimah

Mobile Number: 0559194301 Email Address [email protected]

Existing Policy details with expiry details if any:

If you answered yes to any of the questions mentioned below, please provide us with the latest medical
report for the related medical condition.

1. Has any application for life or disability cover ever been refused, postponed  Yes √ No
or accepted with an extra premium or with special terms?

2. Are you exposed to any particular dangers in the pursuance of your  Yes √ No
profession or in your leisure time (such as handling dangerous materials,
prolonged stays in countries outside of Europe, practicing dangerous and
hazardous sport such as private aviation, gliding, motor-gliding or hang-
gliding, parachuting, diving, Skiing, mountaineering, martial arts, motor
sports or any racing)? Please
specify………………………………………………….

3. Do you suffer or have you ever suffered from diseases or disturbances


effecting the:

a) Heart, Circulation or Cardiovascular System (e. g. hypertension,  Yes √ No


coronary artery disease, cardiac defects, stroke, angina pectoris,
thrombosis)
If yes; please specify the disease and treatment and provide medical
reports where-ever
applicable……………………………………………………………………

b) Brain (e. g. vertigo, frequent headaches, migraine)  Yes √ No


If yes; please specify the disease and treatment and provide medical
reports where-ever
applicable……………………………………………………………………

c) Blood (e. g. blood-clotting disorder)  Yes √ No


If yes; please specify the disease and treatment and provide medical
reports where-ever
applicable……………………………………………………………………
d) Respiratory Organs (e. g. asthma, repeated or chronic bronchitis,  Yes √ No
allergic rhinitis)
If yes; please specify the disease and treatment and provide medical
reports where-ever
applicable……………………………………………………………………
e) Ears (e. g. impairment or acute loss of hearing, tinnitus)  Yes √ No
If yes; please specify the disease and treatment and provide medical
reports where-ever applicable
f) Eyes (e. g. impaired vision) –  Yes √ No
in case of ametropia please indicate: diopters left ......... right..........
g) Larynx, Thyroid  Yes √ No
If yes; please specify the disease and treatment and provide medical
reports where-ever
applicable……………………………………………………………………

h) Pancreas, Liver (e. g. hepatitis, icterus), Spleen  Yes √ No


If yes; please specify the disease and treatment and provide medical
reports where-ever
applicable……………………………………………………………………

i) Kidneys (z. B. kidney stones), Urinary Tract and Genitals  Yes √ No


If yes; please specify the disease and treatment and provide medical
reports where-ever
applicable……………………………………………………………………

k) Oesophagus (e. g. reflux disease), Stomach (e. g. gastric ulcers,  Yes √ No


chronic gastritis)
If yes; please specify the disease and treatment and provide medical
reports where-ever
applicable……………………………………………………………………

l) Nervous System or the Psyche (z. B. seizure disorder, multiple  Yes √ No


sclerosis, paralysis, mental-health problems, depressions, eating
disorders)
If yes; please specify the disease and treatment and provide medical
reports where-ever
applicable……………………………………………………………………

l) Bowels (e. g. morbus crohn, colitis ulcerosa, duodenal ulcers)  Yes √ No


If yes; please specify the disease and treatment and provide medical
reports where-ever
applicable……………………………………………………………………
m) Musculoskeletal System (e. g. spinal column, intervertebral discs,  Yes √ No
shoulder-, hip-, or knee-joints, dysfunctions of muscles, tendons, joints
and/or ligaments)
If yes; please specify the disease and treatment and provide medical
reports where-ever
applicable……………………………………………………………………
n) Skin (e. g. eczema, allergy)  Yes √ No
If yes; please specify the disease and treatment and provide medical
reports where-ever
applicable……………………………………………………………………
o) or have examinations resulted in diagnosing Tumours (e. g. cancer),  Yes √ No
Diabetes, Allergies, Rheumatic Diseases (e. g. chronic arthritis),
Gout, Poisoning, Infectious Diseases, elevated Blood Lipids (e. g.
Cholesterol) or elevated Liver Function Tests?
If yes; please specify the disease and treatment and provide medical
reports where-ever
applicable……………………………………………………………………
4. Do you suffer from any other physical or mental impairments (e. g.  Yes √ No
congenital handicaps, deformities, impairments following operations,
infections, accidents, or amputations)?
If yes; please specify the disease and treatment and provide medical
reports where-ever
applicable……………………………………………………………………
5. Do you take medicines or drugs on a regular basis?  Yes √ No
If yes; please specify the disease and treatment and provide medical
reports where-ever
applicable……………………………………………………………………

6. Did you undergo any medical examinations, treatments or consultations  Yes √ No


by doctors within the last 5 years other than regular check-ups with
normal findings?
If yes; please specify the disease and treatment and provide medical
reports where-ever
applicable……………………………………………………………………

7. Have you undergone operations or treatments in hospitals or at health  Yes √ No


resorts during the past 10 years, or have any of the latter been planned
and advised to be taken into consideration?
If yes; please specify the disease and treatment and provide medical
reports where-ever
applicable……………………………………………………………………

8. Has an HIV infection been detected?  Yes √ No


9. Please indicate your height and your current weight .............. cm ................... kg

10. Are you suffering from any Auto-immune disorders like Gullian-Barre Syndrome,
Psoriasis, Rheumatoid Arthritis, Ulcerative colitis, Multiple Sclerosis  Yes √ No
If yes; please specify the disease and treatment and provide medical reports
Where-ever applicable………………………………………………………

11. Are you planning for surgery for any recently ailment diagnosed recently  Yes √
 No
If yes, please provide the details of surgery posted for and provide medical reports
Where-ever applicable……………………………………………………………………

.
12 Following questions need to be answered by Female member;

a) Please provide your marital status √


 Married  Single

b) Have you suffered/are you suffering from any Gynecological problems?


 Yes √ No
c) Are you pregnant at present? (Yes/No) If yes, Please fill the pregnancy declaration
form.

d) Have you ever undergone any investigation or treatment or received medical advice
or consulted a physician for

i) Any disease or disorder in the cervix, uterus, ovary (ies) or vagina; abnormal
bleeding, cancer or abnormal growth?  Yes √
 No

ii) Any disease or disorder of breast(s), such as breast lump, cyst, fibrocystic
disease, cancer or abnormal growth?  Yes √ No

iii) Have you undergone mammogram or pap smear recently  Yes √ No


If yes; please specify provide medical reports………………

General Declaration from the Member


If you are suffering from any critical illness such as cancer, Cerebrovascular accident –Stroke
and related complications, Vertebral column and spinal injury, Organ failure, bedridden
status; please provide further data, such as name of the respective disease, time and
duration and whether it has been cured completely without leaving any problems. Please
give the name of doctor in charge.

…………………………………………………………………………………………………………..
…………………………………………………………………………………………………………..
…………………………………………………………………………………………………………..

I declare that the answers I have given are, to the best of my knowledge, true and that I have not
withheld any material information that may influence the assessment or acceptance of the proposal.

I understand that this form will constitute an integral part of my proposal for life assurance/ medical
insurance and that failure to disclose any material fact known to me/ any mis-representation in this
form may invalidate the assurance/insurance contract.

Date 28/04/2023 Signature of the person to be insured

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