DECLARATION OF HEALTH

MEDICAL APPLICATION FORM

• This application form shall become an integral part of your insurance contract (policy) therefore, it is important to complete
the application form in clearly legible hand – writing. The application form must be completed by the principal
member/ applicant who intends to hold the policy in his/ her name (the Principal Member /Applicant must be above 18
years of age).
• Please use CAPITAL LETTERS while filling – in this application for and tick the appropriate answer box.
• The application form once duly complete, must be received by us within 30 days from date of signing the application
form. If signing date exceeds 30 days, the application form shall require revalidation by countersignature in current
date.
• Please countersign next to each alteration/ correction in the application form

Please Note:
• If a pre–existing medical condition and/or existing pregnancy is NOT FULLY DISCLOSED, we may decline the claim
relating to it (or its consequences). Therefore, it is in your best interest to disclose your medical history completely.
• In case where your application is approved for medical insurance, your cover shall start on, or after, the date on which
your application is approved/risk is underwritten.
• A ‘pre-existing medical condition’ means any disease, illness and/or injury diagnosed by a physician (even if no
treatment was advised) or brought into a person’s awareness at any time prior to applying for medical insurance due
to which the individual experiences symptoms, receives treatment and/or incurs expense related to it.

1. Member Details (Principal Member/Applicant who intends to hold the policy as ‘Policyholder’)

Applicant’s Name ROULA ALHALABI

Relationship with the
proposed insured
WIFE
Address APT 1603, AL ANWAR TOWER, AL KHAN CORNICHE ST, SHARJAH, UAE

P.O. Box 44156 DUBAI Email address ROLAHALABI2@GMAIL.COM

Contact Number +971529725911 Emirates ID 784-1972-4379815-0

Occupation HOUSE WIFE Sponsor’s Name Luai ALRANTISI

Salary (AED) Up to 4,000 Above 4,000

2. Details of Existing or Previous Insurance

Do you have existing or previous health insurance with Sukoon Insurance PJSC (hereinafter Yes No
referred to as "Sukoon") or existing valid health insurance with any other insurer in the UAE?
If yes, please provide
details ( Policy number),
expiry date

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3. Details of Members to be insured (Self, Spouse & Children)

Passport/Emirates Marital Date of Visa

Name Nationality Relationship Gender Height Weight
ID Number Status Birth Emirate

ROULA ALHALABI CANADA 784-1972-4379815-0 WIFE MARRIED 21/Oct/1972 FEMALE 162 72 DUBAI

4. Medical History

1. Have you ever been diagnosed or investigated for a medical condition requiring regular
outpatient treatment, follow – ups or specialized investigations (Ultrasound/MRI/CT scan) Yes No
or inpatient treatment/hospitalization? If yes, please specify condition/s and attach
applicable test results:
a. Have you been diagnosed for High blood sugar (Diabetes mellitus)?
Yes No
i. Are you taking Insulin (Diabetes Mellitus type 1)?
Yes No
ii. Have you been diagnosed or investigated for diminished vision (retinopathy),
kidney impairment (nephropathy) or numbness of limbs (neuropathy) or Yes No
advised for hospitalization?
b. Have you been diagnosed with High blood pressure (Hypertension) and/ or
abnormal lipid profile (Dyslipidemia/ Hyperlipidemia)? Yes No
Yes No
i. Have you been investigated or diagnosed for chest pain (angina pectoris) or
any heart disease (coronary artery/ ischemic heart disease, cardiomyopathy, or
heart valve incompetence)?
c. Have you been diagnosed with disease or disorder of Thyroid Gland with or without Yes No
abnormal thyroid function tests (Hypothyroidism, Hyperthyroidism)?

i. Do you have Enlarge thyroid (Thyroid nodule, Multinodular Goiter) with or

without past history of surgical treatment or Needle Biopsy? Yes No

ii. Have you been diagnosed with Hyperthyroidism, Thyroiditis or Graves’ disease
with or without past history of surgical treatment or Needle Biopsy? Yes No

d. Have you been diagnosed for Breathlessness or experienced whistling sound on

breathing (Asthma)? Yes No

i. Have you visited to an emergency room or hospitalized for treatment of Asthma?

Yes No
e. Do you have any other medical conditions, Physical or mental disorder/disability not
listed above? Yes No
2. Are you currently Pregnant?
Yes No
a. Is your pregnancy single or multiple (twin, triplet etc.) Single Multiple
b. Are there any pregnancy complications (Fetal Growth Retardation or
Congenital anomaly etc.)? Yes No

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4. Medical History (Continued)

c. Expected date of delivery d d mm y y y y

d. Are you currently trying to get pregnant? Yes No
e. Are you undergoing any form of fertility Yes No
treatment?
f. 2 20 6 2 0 24 2 00 7 2 0 24
Input Last two Menstrual Dates
3. Have you ever been treated or diagnosed with Lump/Cyst/Cancer/Tumor? Yes No
4. Have you undergone surgery or advised a surgery or currently hospitalized or requiring Yes No
daycare or inpatient treatment?
5. Do you have any sign, symptom, sickness requiring treatment or medications or have Yes No
been advised to take any medication or treatment for more than 07 days or are you
currently taking any medication?

6. Have you visited clinics/ hospitals for assessment, Physiotherapy & treatment for back Yes No
pain (e.g., Neck Pain, Low Back Pain, etc.)?

5. Specific Medical History

Please confirm if you have / had received treatment or been investigated for any of the following medical conditions.
You may select multiple answers (if you meet more than one condition).
1. Birth Malformation, congenital
condition, Developmental disorder 2. Blood disease (Anemia,
Leukemia, Polycythemia,
3. Chronic Obstructive Pulmonary Thrombocytopenia)
Disease Chronic bronchitis,
Bronchiectasis) 4. Chronic Kidney disease,
Renal impairment/
5. Bipolar Disorder Failure
7. Cerebrovascular Stroke (CVA) 6. Chronic liver disease, Cirrhosis of liver
9. Communicable Disease 8. Cataract
11. Diverticulosis of intestine 10. Crohn’s disease
13. Enlarge tonsils or adenoids 12. Cystic Fibrosis
15. Hemorrhoids, Piles 14. Head Injury
17. Hypersplenism 16. Heart Disease or Heart Failure
19. Immunodeficiency state specified 18. Hernia (Inguinal, umbilical, incisional)
21. Myasthenia Gravis 20. Kidney or Gall bladder stone
23. Optic Neuritis 22. Motor neuron disease
25. Organ Transplant 24. Multiple sclerosis
27. Prostate Enlargement (Male) 26. Osteoarthritis (Knee or Hip)
29. Psoriasis 28. Pancreatitis
31. Retinal detachment 30. Rheumatoid arthritis
33. Ulcerative colitis 32. Sinusitis, Nasal Polyp
35. Viral Hepatitis (B, C or Delta) 34. Varicose veins of lower etremities
36. Others

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6. Please provide details of ALL questions which have been answered YES for Self and Dependent (s) in the below table

Member’s Question Medical Condition/ Type Date of Details of Name of

Name No. of Disorder Onset Treatment Hospital/ Clinic

da

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6. Declaration

I declare that I have clearly understood the terms and conditions of the product I am applying for and have clearly
understood its features and benefits including the exclusions. I further declare that I have answered all the questions in this
proposal form after clearly understanding them and that I have duly signed this proposal at required places. I confirm to have
fully understood the nature of the questions and the importance of disclosing all information while answering such
questions. I declare that the answers given by me to all questions in the proposal form are true and complete in every
respect and that I have not withheld any material information or suppressed any material fact. I undertake to notify
Sukoon of any change in any information given by me in this proposal form. I confirm that I clearly understand that in
case of any misstatement, misrepresentation and/or suppression of any data and/or information and/or where I do not
immediately inform Sukoon of any changes in information provided in this proposal form, Sukoon has the right to
repudiate any and all claim(s) under any policy if issued based on this proposal form and/or at sole discretion of Sukoon
to consider any issued policy based on this proposal form as cancelled or void.

I hereby authorize Sukoon i) to contact me anytime and through any medium (phone, email, sms, telephone etc.) for
purpose of obtaining more information about this proposal form and/or for keeping me informed about their other
products and/or promotion activities, ii) to collect, store, process, share and transfer your personal data (including but not
limited to your personal sensitive information) to to third parties including but not limited to reinsurers, surveyors, loss
adjustors, loss assessors
, IT service providers, claim administrators, medical providers, emergency support/assistance providers, professional advisors,
consultants,auditors, additional administrative and/or support service providers, and other entities or persons , whether
within or outside the UAE , as may be required in relation to underwriting/ issuing/administering / processing/ reinsuring
your policy/ claims or as may be required by Sukoon including but not limited to for further product development/statistical
analysis etc., or as may be required under law/regulatory requirements.

I hereby also authorize my past/present employer/business associates, medical

practitioner(s)/hospitals/laboratories/medical providers, insurance companies, financial institutions to release to Sukoon all
details, records, facts and information (including medical details, KYC records, AML-CTF &FATCA details) as required
anytime by Sukoon for assessment of risk and/or for processing of claims if subsequently an insurance policy is issued
based on this proposal form. This proposal form shall be a part of the insurance policy in case of its acceptance by Sukoon.
I understand that I should be having DHA compliant insurance policy if I or my dependents are holding Dubai visa and a
Department of Health, Abu Dhabi compliant insurance policy if I or my dependents are holding an Abu Dhabi/Al Ain Visa. I
hereby agree to notify Sukoon in case my visa changes during a policy year to be enrolled under an Insurance policy that
is compliant with respective regulator.

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. 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. The insurer has the right not to cover
(reject) any claims relating to undeclared pregnancy or if the intention to get pregnant is not declared in the application
form.

I acknowledge that no liability from the part of Sukoon shall be accepted against medical conditions existing or originating
prior to the inception date of insurance policy if any issued, unless otherwise indicated on the Table of Benefits of my
policy. Furthermore I understand and accept that failure on my part to notify Sukoon of any such existing medical
conditions will be considered misrepresentation and will prejudice the acceptance of such claims by Sukoon.

Applicant’s Name
Roula Alhalabi 2/Aug/2024
Date (dd/mm/yy)

Emirates ID Number
Applicant’s Signature

784-1972-4379815-0