Medical Application Form - Fillable
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3Medical Application Form
Insured Name:
Inception Date:
Required Plan:
Policy No.:
Photo
UAE
NAME please specify Employee (E), Child (C) or Spouse (S)
Relation
D. O. B.
Nationality
Sex
Height
Weight
card
Resident
First Name
Middle Name
Family Name
E/S/C
DD/MM/YY
M/F
CM
KG
Yes/No
Has Dubai Insurance 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:
Dubai
Street:
City:
P.O. Box:
Tel. No:
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
11. Pregnancy, complications of pregnancy, child birth and
the puerperium incl. abortions
2. Neoplasms/Cancer (benign or malignant)
12. Disease of the skin and subcutaneous tissue
3. Diseases of the endocrine system, nutritional-,
13. Diseases of the musculoskeletal system and
metabolic diseases and immunity disorders, diabetes
connective tissue
4. Diseases of blood and blood forming organs
14. Congenital anomalies, hereditary/genetic diseases
5. Mental-/psychiatric disorders
15. Certain conditions originating in the perinatal period
6. Diseases of the nervous system and sense organs
16. Injury and poisoning
(ears, eyes, nose)
7. Diseases of the cardiovascular system
17. Previous medical/surgical hospitalisations, procedures
incl. hypertension
and operations
8. Diseases of the respiratory system
18. Any (chronic) disease(s), symptoms and complaints not
mentioned above
9. Diseases of digestive system
19. Any Pre-existing disease(s), symptoms and complaints
within the last ten years
10. Diseases of genitourinary system, kidney diseases
and breast disorders
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Parent category: Business