Medical Application Form

Insured Name: Application Date:

Required Plan: Application/Policy No.:

Current Address: …………………………………………………………………………………………………………………

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

 Self and Family Insurance details for ALL members:

FULL NAME RELATION MARITAL D. O. B. NATIONALITY GENDER HEIGHT WEIGHT UAE Already
First Middle Last E/S/C STATUS DD/MM/YY M/F CM KG Resident Insured
(Yes/No)
(Yes/No)
Insured
Since

PREVIOUS

Insurer TPA SI Expiry Date

Is there a member in your family that is not proposed for Insurance? Yes/No
If Yes, Kindly share reason for each member
……………………………………………………………………………………………………………………………………………………
…………………………………………………………………………………………………………………………

 Active at work since: …………………………………

 Insurance History (in case answer is "Yes," specify reason/ details)

a. Have you ever been accepted for life and/or health insurance on sub -standard terms?
b. Have you ever been declined for life and/or health insurance?

 Do you participate or intend to participate in any amateur/professional/hazardous sport activities? Yes/No

If Yes, …………………………………………………………… …………………………………………………………………….
Hav e you ev er been diagnosed or received any treatment (including hospital or surgery) or felt any disorder or pain or had any symptoms indicating:
(Please tick relevant box) Yes / No Yes / No
1. Infectious and parasitic diseases 13. Musculoskeletal and/or Connective Tissue
System? (I.e. fractures, joint or cartilage problems,
back problems, bone infections, osteoporosis,
arthritis, rheumatism, etc.)

2. Cancer, Neoplasms, Tumors? (specify below 14. Congenital anomalies, hereditary/genetic

the type, location, treatment, whether malignant or diseases
benign)

3. Diseases of the endocrine system, nutritional-, 15. Certain conditions originating in the perinatal
metab Endocrine, Nutritional, Metabolic and/or period
Immunity System? (i.e. diabetes, thyroid or pituitary
gland problems, adrenal gland, ovary or testes
problems, hormone problems, gout, multiple
sclerosis, cystic fibrosis, metabolic disorders,
immune problems, etc.)Colic diseases and immunity
disorders, diabetes
4. Blood & Blood Forming Organ Systems? (i.e. 16. Injury and poisoning
anemia, thalassemia, bleeding disorders, blood cell
disease, spleen problems, lymph node problems,
etc.)
5. Mental-/psychiatric disorders 17. Previous medical/surgical hospitalizations,
procedures and operations

6. Nervous System or Sense Organs? (i.e. ear 18. Any (chronic) disease(s), symptoms and
injury/infection, vertigo, hearing problems, eye complaints not mentioned above
injury/disease, retina problems, glaucoma, vision
problems, muscular dystrophy, brain/nerve
degeneration, meningitis, paralysis, seizures,
epilepsy, neuralgia, etc.)
7. Cardiovascular System? (i.e. stroke, cerebral 19. Any Pre-existing disease(s), symptoms and
ischemia, rheumatic fever, atherosclerosis, complaints I within the last ten years
aneurysm, embolism, peripheral vascular disease,
hypertension, heart valve disease, irregular
heartbeat, pulmonary embolism, phlebitis,
varicosities, etc.)
8. Respiratory System? (i.e. Sinusitis, allergies, 20. Have you ever undergone surgery to remove a
tonsillitis/laryngitis, bronchitis, emphysema, body organ or structure or being hospitalized in the
pneumonia, etc.) past? (Specify body organ/Structure, date & place
of surgery?)
If Yes, have there been any complications to date?
9. Cirrhosis/ Hepatitis / Wilsons disease / 21. Are you presently in good health, entirely free
Pancreatitis/ Liver disease / Cohn’s disease / from any physical/mental impairment and
Ulcerative Colitis /Piles or any other disease of deformity? If no please provide the details
Mouth , Esophagus , Liver , Gall bladder , Stomach
or Intestines or any other part of Digestive System?

10. Genitourinary System? (i.e. Kidney/bladder 22. Has there been any Loss/Gain of wait in last 12
infections, renal failure, kidney stones, months? Yes No (If yes please provide details)
endometriosis, menstrual cycle problems,
salpingitis, ovarian cysts, prostate problems,
impotence, testicle infections, sperm abnormalities,
fertility problems, Breast disorder etc.)
11. Do you have earlier history of Caesarean 23. Smoke, consume alcohol, or chew tobacco or
Section, Premature Delivery or Premature babies? use any recreational drugs? If Yes please then
Or any other complications related to maternity, till provide the frequency and amount consumed
date?

24. Have you ever suffered from dental problems? YES/NO

(b) If, yes, specify same.
(c) When were you treated last for same?
 Please Note:
1. In case the answer is YES to any of the conditions/diseases above , please specify full details (preferably by a
Medical Physician) on the additional questionnaire (Personal Information), which will be found attached to this
application form.

2. In case medication is required on a regular basis please specify the full details such as genuine name, brand
name and daily/weekly quantity on the additional questionnaire (Personal Information), which will be found
attached to this application form.

For Married Females:

Yes No
- Are you currently pregnant?
- If yes, have there been any complications to date? -
- Last Menstrual period date:
- Are you currently trying to get pregnant?
- Are you undergoing any form of fertility treatment?

I 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. I also acknowledge and
understand any pregnancy, which arises within forty calendar days fro m the date of this application, shall not be covered under
this policy under any condition.

I agree that no indemnity will be paid under the proposed insurance policy for medical expenses arising from disorders which were
declared prior to completion of this Application and 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 hereby declare and agree, with respect to both, myself and to my Dependents, that I am aware of the general terms of this
insurance and I accept them. With the above, I authorize my doctor, previous Insurer, Previous TPA, health institution or other
organization or person that has any information about my health and/or activities (and those of my Dependents) to provide the
Insurer with the said information. This shall include hospital and any other records pertaining to medical advice, diagnosis,
treatment or disturbances. A photocopy of this authorization has the same validity as the original.

I the undersigned declare that all of the above information as well as all declarations on the additional questionnaire (personal
information) are true and complete. This information shall be considered as an integral part of the insurance policy.

Date: Signature:

Note: To be treated as confidential once completed

Medical Conditions

Nam e of applicant Age: Sex:

Date of application: / / (dd/mm/yyyy)

Medical condition/diagnosis:
(if more than one sickness, please complete a separate form for each)

Date of last treatm ent/sym ptom s: / / (dd/mm/yyyy) ongoing treatment = current date

Diagnosis Status: Yes No

 Cured/ no symptoms
 Ongoing symptoms
 Ongoing hospitalization
 Pending hospitalization
 Ongoing treatment
 Pending treatment

In case of any Diagnosis Status the applicant w as treated as:

 Outpatient
 Hospitalized
 Treated both w ays
 Operated on: / / (dd/mm/yyyy)

How often do the sym ptom s occur? …………………………………………

Or Can the illness be described as follow s?

 Acute
 Chronic
 Recurrent

Did you ever have any bone fractures or injuries to bones or

tendons? Has any m aterial used for osteosynthesis etc. been
rem oved?

Any dim ness of vision or cataract etc

Have you been tested or treated for Hepatitis A or C?

In case m edication is required on a regular basis please specify the genuine name,
the brand name as well as the daily/w eekly quantity below .

……………………………………………………………………………………………….

In case you are sufferin g from hypertensio n please specify your Systolic and Diasto lic readin gs below .

Systolic:
Diastolic:

In case of diabetes please specify w hether insulin dependent,

Please specify the generic name / brand name as well as the daily / weekly quantity below
KNOW YOUR CUSTOMER FORM (KYC) – INDIVIDUKNOW YOUR CUSTOMER FORM (KYC) – INDIVIDUALKNAL

MEDICAL PRACTITIONER( S) MOST FREQUESNTLY VISITED IN THE LAST 2 YEARS:

• Name:
• Address:
• Telephone No.:

CANCER

Are you suffering or ever suffered with any type of Cancer? Yes/no

If yes, kindly share the current status

a. Cured/ no symptoms
b. Ongoing symptoms
c. Ongoing hospitalization/ Treatment
d. Pending hospitalization/ Treatment

Kindly provide full details of past, current or advised pending treatment:

a. Diagnosis
b. Surgery
c. Chemotherapy cycles
d. Radiotherapy cycles
e. Radiation cycles
f. All other medication

Do you have any FAMILY HISTORY of Cancer? Yes/No

If Yes, provide details
……………………………………………………………………………………………………………………………………………………………
…………………………………………………………………………………………………………………………………

Date: Signature:

Note: To be treated as confidential once completed

KNOW YOUR CUSTOMER FORM (KYC) – INDIVIDUKNOW YOUR CUSTOMER FORM (KYC) – INDIVIDUALKNAL

KNOW YOUR CUSTOMER FORM (KYC) – INDIVIDUAL

Important Instructions: Fill the form completely & mark NA where Not Applicable

INSURANCE DETAILS

Application Type ☐ New ☐ Renewal

Class of Insurance required

APPLICANT DETAILS

Full Name as per ID

Date of Birth Place of Birth

Gender ☐ Male ☐Female

Nationality

Mobile no

Email Address

Residential Status ☐ UAE Citizen ☐ Resident ☐Non-resident

Address in UAE

☐ Salaried (Private Sector) ☐ Salaried (Public Sector)

Occupation Type ☐ Business Partner/Owner ☐ Freelancer
☐ Unemployed

Employer Name & Address

Job Title
☐ Below AED 15,000
Monthly Income
☐ Above AED 15,000
In the last 6 months, have you
submitted any KYC documents ☐ Yes ☐ No
to
DIN
If yes, For which class of Insurance

IDENTIFICATION DETAILS

ID Type ☐ Emirates ID ☐ Passport ☐ GCC ID

ID Number

ID Expiry Date
POLITICAL EXPOSED PERSON (PEP) DECLARATION: Natural persons who are or have been entrusted with
prominent public functions in the State or any other foreign country such as Heads of States or Governments, senior
politicians, senior government officials, judicial or military officials, senior executive managers of state-owned corporations,
and senior officials
of political parties and persons who are, or have previously been, entrusted with the management of an international
organization or any prominent function within such an organization.
Do you classify yourself as a PEP or are you a direct relative or known associate of a
PEP If Yes, please specify details of PEP

Name

Title/Designation

PEP Type ☐ Domestic PEP ☐ Foreign PEP ☐ Head of International Organizations (HIO)

PAYER DETAILS (IF PAYMENT IS MADE BY A THIRD PARTY)

Name

Nationality

Relationship

ID Number

ID Expiry Date
☐ Below AED 15,000
Monthly Income
☐ Above AED 15,000

CUSTOMER DECLARATION

☐ I declare that the above details are true and correct to the best of my knowledge and belief. I undertake to
inform you of any changes in the above information. In case any of the above information is found to be false
or misrepresented, I am aware that I will be held accountable and liable for legal action.

☐ I hereby also confirm that I am not a resident for Tax purpose in any country other than UAE, though one or
more parameters may suggest my relationship with the country outside UAE. Therefore, I am providing my
Emirates ID document as proof of my citizenship or residency in the UAE region.

☐ I hereby confirm that I am NOT a US person as defined in the FATCA regulations.

______________________
Signature of the Customer Date:

Note: The KYC Documents, information, and PEP Declaration should be collected in accordance with the Central Bank Directive and Cabinet Decision
No. (10) Of 2019. Any information shared with DIN will be treated with utmost confidentiality and will be utilized strictly by the AML Compliance team
of DIN and there are no cross border transfer of any data carried out by the staff of DIN, except at an event of an adverse situation where DIN would
be obliged to provide the information requested by the Law enforcement authorities and or Supervisory Authorities (CBUAE, Financial Intelligence Unit
or the Executive Office, etc.) of UAE.