Medical Application Form

Insured Name: Inception Date:

Required Plan: Policy No.:

NAME please specify Employee (E), Child (C) or Spouse (S)

Height Bahraini
Relationship D.O.B Nationality Sex Weight CPR NO.
CM Resident
First Name Middle Name Family Name

Has any of the above applicants have been previously insured? Yes No
Has “Solidarity” previously covered any of the above applicants? Yes No
Is there a member in your family that is not proposed for Insurance? Yes No If Yes, please explain under section Comments

Marital Status: No. of Children: Active at work since:

House/Flat/Building: Road: Block:
Area: P.O. Box: Contact No.:
Email:

I hereby declare and agree, with respect to both, myself and to my Dependants, that I am aware of the general terms of
this insurance and I accept them. With the above, I authorise my doctor, health institution or other organisation or person
that has any information about my health and/or activities (and those of my Dependants) 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 authorisation has the same validity as the original.

Have you ever 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 10. Diseases of genitourinary system, kidney diseases
and breast disorders
2. Neoplasms/Cancer (benign or malignant) 11. Pregnancy, complications of pregnancy, child birth
and the puerperium incl. abortions
3. Diseases of the endocrine system, nutritional-, 12. Disease of the skin and subcutaneous tissue
metabolic diseases and immunity disorders, diabetes
4. Diseases of blood and blood forming organs 13. Diseases of the musculoskeletal system and
connective tissue
5. Mental-/psychiatric disorders 14. Congenital anomalies, hereditary/genetic diseases

6. Diseases of the nervous system and sense organs 15. Certain conditions originating in the perinatal period
(ears, eyes, nose)
7. Diseases of the cardiovascular system 16. Injury and poisoning
incl. hypertension
8. Diseases of the respiratory system 17. Previous medical/surgical hospitalisations,
Procedures and operations
9. Diseases of digestive system 18. Any (chronic) disease(s), symptoms and complaints
Not mentioned above

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 (Medical Condition Form), which will be found attached to this application form (page 3).

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 (Medical Condition Form), which will be found attached to this application form (page 3).

SOLIDARITY BAHRAIN B.S.C.

P.O. Box 18668, Manama – Kingdom of Bahrain
Tel.: +973 17 585222 Fax: +973 17 585200 e-mail: [email protected] web: www.solidarity.com.bh
Comments:

Only to be filled out if you have answered “Yes” in the question of any family members, who is not proposed for
Insurance.

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 agree, with this in respect to both, myself and my Dependants that I am aware of the general terms of this
insurance and I accept them for myself and on behalf of my dependants. 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:

SOLIDARITY BAHRAIN B.S.C.

P.O. Box 18668, Manama – Kingdom of Bahrain
Tel.: +973 17 585222 Fax: +973 17 585200 e-mail: [email protected] web: www.solidarity.com.bh
Medical Condition

Name 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 treatment/symptoms: / / (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 was treated as: Yes No
 Outpatient
 Hospitalized
 Treated both ways
 Operated on: / / (dd/mm/yyyy)

How often do the symptoms occur? Or can the illness be described as follows? Yes No
 Acute
 Chronic
 Recurrent

Did you have any bone fractures or injuries to bones or tendons?

Has any material used for osteosynthesis etc. been removed?

In case medication is required on a regular basis please specify the genuine name,
the brand name as well as the daily/weekly quantity below.

In case you are suffering from hypertension please specify your Systolic and Diastolic readings below.

Systolic:
Diastolic:
In case of diabetes please specify whether insulin dependent. Yes No

Date: Signature:

SOLIDARITY BAHRAIN B.S.C.

P.O. Box 18668, Manama – Kingdom of Bahrain
Tel.: +973 17 585222 Fax: +973 17 585200 e-mail: [email protected] web: www.solidarity.com.bh