Medical Application Form (Page 3 of 4) in pdf

Medical Application Form Page 3

9. Diseases of digestive system( Peptic or gastric ulcer , reflux , gastritis ,

19. Any Pre-existing disease(s), symptoms and complaints within the last ten

bleeding varices , intestinal obstruction ,inflammatory bowel disorders , Colitis ,

years

chron’s disease ....)

10. Injury and poisoning

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.

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.

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:

ORIENT INSURANCE PJSC

P.O. Box 27966, Dubai – UAE

Tel.: +971 4 253 1300 Fax: +971 4 251 5079

Medical Application Form Page 3