Form No.

MEDICAL APPLICATION FORM

Please note that:
The application should accompany the following documents:
Copy of passport with valid visa page
A recent photograph

False declarations shall render the insurance coverage invalid from the effective date, with no refund of premium.

guidelines

Name of Main Applicant (exactly as appearing in the passport- IN CAPITAL LETTER):

First Name Middle Name Last Name

Mailing Address:

City Country Gender:

Marital Status: Nationality: Country of Origin:
Contact Details: (a) Mobile: (b) e- mail:
Gross Salary Band/Month: AED 4000 and below (LSB) AED 4001 and above(NLSB)
Note: Dependents will be considered as LSB or NLSB in line with the salary band of the principal member

Visa Issuance Emirates: Dubai Abu Dhabi/ Al Ain Others

Members’ Schedule - All Family Members (Main Applicant as Member No. 1)
(Please use additional sheet if more space is required)
Member Date of Birth Height Weight
Name Relationship
No. (dd-mm-yyyy) (Cm) (Kg)
1 / /
2 / /
3 / /
4 / /
5 / /
Chapter A
Insurance History (in case answer is "Yes," specify reason) Yes No

1. Have you ever been accepted for life and/or health insurance on sub-standard terms?
2. Have you ever been declined for life and/or health insurance?
3. Are the proposed persons, already insured under a health insurance plan with Takaful Emarat or any
other insurance company?
Chapter B
Extra Activities Yes No
1. Do you participate or intend to participate in any amateur/professional/hazardous sport
activities?
2. Do you ride motorcycles and/or Electric scooters?
Chapter C
Specific Medical History (if "Yes," specify diagnostic details, treatment received & recovery status) Yes No
1. Have you ever been diagnosed, treated or felt any disorder, pain or had any symptoms related to the:
a) Musculoskeletal & /or Connective Tissue System? (i.e.: fractures, joint or cartilage problems,
back problems, deformities, bone infections, osteoporosis, arthritis, rheumatism, etc.)
b) Cancer, Neoplasms, Tumors? (specify type, location, treatment, whether malignant or benign)
 c) Blood & Blood Forming Organ Systems? (i.e.: anemia, thalasemia, bleeding disorders, blood
cell disease, spleen problems, lymph node problems, etc.)

Chapter C
Specific Medical History (continued from previous page) Yes No
d) Digestive System? (i.e. reflux, ulcers, diverticuli, bleeding-infection-obstruction-perforation of the
esophagus, stomach, intestines or colon, problems of the teeth/gums/mouth/jaw, problems with the
liver, gallbladder or pancreas, anal/rectal polyps?
e) Endocrine, Nutritional, Metabolic and/or 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.)
f) Nervous System or Sense Organs? (i.e. ear injury/infection, vertigo, hearing problems, eye
injury/disease, retina problems, glaucoma, vision problems, muscular dystrophy, brain/nerve degeneration,
meningitis, paralysis, seizures, epilepsy, neuralgia, etc.)
g) Genitourinary System? (i.e. kidney/bladder infections, renal failure, kidney stones,
endometriosis, menstrual cycle problems, salpingitis, ovarian cysts, prostate problems, impotence,
testicle infections, sperm abnormalities, fertility problems, etc.
h) Respiratory System? (i.e. sinusitis, allergies, tonsillitis/laryngitis, bronchitis, emphysema, pneumonia, etc.)

i) Cardiovascular System? (i.e. stroke, cerebral ischemia, rheumatic fever, atherosclerosis, aneurysm,
embolism, peripheral vascular disease, hypertension, heart valve disease, irregular heart beat,
pulmonary embolism, phlebitis, varicosities, etc.)
j) Skin-Subcutaneous Tissue? (i.e. dermatitis, acne, seborrhea, puritis, etc.)

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

l) Any (chronic) disease(s), symptoms and complaints not mentioned above

2. Have you ever undergone surgery to remove a body organ or structure or being hospitalised
in the past? (specify body organ/ Structure, date & place of surgery?)
3. Are you HIV positive or have any medical condition or symptom indicative of HIV infection or AIDS

• Are you currently pregnant? (Applicable for married females) Yes No

• 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?_____________________________________________________

• Do you have earlier history of Caesarean Section, Premature Delivery or Premature babies? Or any other complications related to maternity, till
date? ________________________________________________________
 Detail of Answers

Please give details of any question if answered ‘Yes’ by first specifying the member's number as indicated on the members
schedule, the chapter, the question number and the explanation details. i.e.: "2-C-3: explanation."

Member Chapter Question

EXPLANATION
No. No. No. Date of Onset Present Status of
Type of Disorder Details of Treatment
dd-mm-yyyy Health
/ /
/ /
/ /
/ /

In case of diabetes please specify whether insulin dependent please specify the generic name / brand name as well as the daily
/ weekly quantity below:

In case currently on immunomodulator or immunotherapy kindly specify the generic name / brand name as well as how often
administration is required:

DECLARATION & AUTHORIZATION:

I hereby declare that what has been stated above is true and complete to the best of my knowledge and belief and I have not
withheld any material information. It is understood and agreed that this declaration which is contained in the application form
constitutes the basis of my/our contractual relationship with Insurance Co through Authorized Third-Party
Administrator and that any non- disclosure or misrepresentation of facts will make my / our insurance coverage void from
inception. I hereby authorize any hospital, physician, surgeon, or any other organization to furnish to the Insurance Co through
Authorized Third-Party Administrator any or all information that may be required concerning my/ our medical history.

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 from the date of this application; coverage will also be at the
discretion of the insurer

Furthermore, I also understand and acknowledge that any ongoing or planned hospitalization not declared at the time of this
applications coverage will be at the sole discretion of the insurer and the Insurer has the right not to cover.

“I hereby provide Takaful Emarat Insurance PSC an unambiguous consent, to contact us for our takaful policy or for any marketing
and promotion of takaful products, to process, share, and transfer the personal information of the members insured to any recipient
whether inside or outside the country, including but not limited to the Company branches, affiliates, reinsurers, business partners,
professional advisers, insurance brokers and/or service providers where the transfer or share, of such personal data is necessary for:
(i) the performance of this Policy; (ii) assisting the Company in the development of its business and products; (iii) improving the
Company’s customers experience; (iv) for the compliance with the applicable laws and regulations”

*Personal Data means all information relating to the member insured (whether marked “personal” or not) disclosed to Takaful
Emarat Insurance PSC by whatever means either directly or indirectly which concerns, including but not limited to, my medical
conditions, treatments, prescriptions, business, operations, contact details, account balances/activities or any transactions
undertaken with Takaful Emarat Insurance PSC.

Applicant’s Signature
Self & on behalf of Family Members

DATE: / /

Underwriting Decision:

Underwriter’s Signature Authorized Signatory’s Signature

DATE: / / DATE: / /