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Major Declaration Form - DUBAICARE, MEDNET, NAS, NEURON, NEXTCARE

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Mukesh Mishra
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33 views2 pages

Major Declaration Form - DUBAICARE, MEDNET, NAS, NEURON, NEXTCARE

Uploaded by

Mukesh Mishra
Copyright
© © All Rights Reserved
We take content rights seriously. If you suspect this is your content, claim it here.
Available Formats
Download as PDF, TXT or read online on Scribd
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MAJOR MEDICAL DECLARATION FORM

DUBAICARE / MEDNET / NAS / NEURON / NEXTCARE / MSH


(To be completed by the HR or an authorized person of the company)

Company Name

Quotation Ref No. Business Activity

E-mail ID Telephone No./Mobile No.

Previous Insurer Previous Policy Expiry Date

We hereby confirm to Dubai Insurance Company that the below information is correct and has been provided after verifying the same
with all members to be insured with us.

S. No Type of Conditions / Diseases / Ailments Yes No

1 Cardiac Illnesses, Ischemic Heart Diseases or Surgeries

2 Cancer / Tumor – (Malignant or Non Malignant)

3 Person in COMA

4 COPD (Chronic Obstructive Pulmonary Disease)

5 Bone Fractures / Bone Diseases / Joint replacement / Disc Prolapse

6 Infertility Treatment

7 Ongoing Pregnancy (Mandatory for groups with 50 lives & below and if mentioned in TOB for endorsements)

8 Gastric problems (including Hiatus Hernia), Liver or Pancreatic Illnesses or Surgeries.

9 Organ Transplants (Done and/or planned)

10 Blood and vascular disorders including Varicose veins.

11 Birth defects/ deformities/congenital illnesses/hereditary or developmental disorders

12 Major Kidney Diseases

Autoimmune Disorders such as but not limited to multiple sclerosis, Rheumatoid arthritis, Systemic Lupus
erythematosus (Lupus), Inflammatory bowel disease (IBS), Addison disease. Celiac disease, sprue (gluten-
13
sensitive enteropathy) Dermatomyositis, Graves’ disease. Hashimoto thyroiditis, Multiple sclerosis.
Myasthenia gravis, Pernicious anemia.

Note: It is important to disclose any and all pre-existing medical conditions or circumstances that may affect your insurance coverage. Failure to do so
may result in Dubai Insurance Co. declining any claims related to these conditions for non-disclosure of material facts. In such cases, policy holder will
be responsible for settling and reimbursing any paid amounts back to Dubai Insurance Co. Therefore, we strongly advise you to disclose all relevant
information to ensure a smooth and hassle-free insurance experience.
Ver01052023
If any of the above are answered “YES”, please provide details below

MAF Reports
Member Name Relation Condition / Diseases / Ailments
Yes No Yes No

Note: Any declaration made regarding the above-mentioned medical conditions will be subject to individual medical application
form evaluation and underwriting. Additional premium charges may apply based on the underwriting assessment.

Declaration:
1. Dubai Insurance Co. has the right to re-underwrite and propose new premiums based on above information
2. Members above age 64 or with pre-existing/chronic conditions will have to submit Individual health declaration
forms.
3. All additional members to the policy will have to declare all pre-existing conditions in relation to above listed
conditions.
4. After inception or the date of period between signed group declaration form and onboarding process of the policy if
we become aware of any of the above conditions previously unreported, we undertake to inform Dubai Insurance
Co. promptly thereafter for their appropriate action.
5. We 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. We 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.
6. By signing this form, we hereby confirm that we have notified our Employees and received their confirmation on the
same.

___________________________________
Name / Designation

___________________________________
Authorized Signatory & Company Stamp Date:
Ver01052023

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