Insurnace Individual & Family Form

Individual & Family Health Insurance
Proposal Form & Medical Questionnaires
M EM BER DE TA I LS
Full Name:
Address:
Nationality:
Marital Status:
Employer:
Occupation:
Fax Number:
Office Phone:
Mobile No.
Name of Plan Selected
Email:
M E M BER A N D D E PE N D E N T I N F O R M A T I O N
Principal
Spouse
First Name
Middle Name
Family Name
Gender
Date of Birth
Height (cms)
Weight(kg)
Emirates ID Number
Previously Insured?
If Yes, please provide

details, where and
how long.
Page 1 of 6
Child 1
Child 2
Child 3

Please answer the following questions for all named applicants. (Please tick the relevant box).
Questions
1
Are you in good health and free from

any defor mity or defect?
Have you ever been declined for

health and/or life insurance?
Have you ever been accepted for

health and/or life insurance on substandard terms?
Do you involve yourself in any

dangerous sporting activities or ride a
motorcycle?
Are you pregnant now? If Yes, when

do you expect to deliver?
10
11
12
PRINCIPAL
YES
NO
SPOUSE
YES
Musculoskeletal &/or Connective

Tissue System i.e. fracture, joint or
cartilage problems, back bone
infections, osteoporosis, arthritis,
rheumatism, etc)
Neoplasm , Cancer, Tumors
(Specify type, location, treatment,
whether malignant or benign)
Blood & Blood Forming Organs
System (i.e. anemia, thalassemia,
bleeding disorders, blood cell, lymph
node problems etc.)
Digestive System
(i.e. reflux, ulcers, diverticulI,
bleeding-infection-obstructionperforation or problems of the
teeth/gum/ mouth/ jaw, liver
problem, gall bladder or pancreas,
anal / rectal polyps etc.
Endocrine, Nutritional, Metabolic
and/or immunity System
( i.e. diabetes, thyroid or pituitary or
testes problems, hormone problems,
go ut, multiple sclerosis, cystic fibrosis,
metabolic disorders, etc.
Nervous System or Sense Organs
(i.e. ear injury/infection, vertigo,
hearing problems, eye vision
problems, muscular dystrophy,
brain/nerve degeneration,
meningitis, paralysis, seizures, etc.
Genitourinary System
( i.e. kidney/ bladder infections,
renal failure, kidney stones,
salpingitis, ovarian cysts, prostate
problems, i mpotence, testicle
infections, sper m abnormalities,
breast disorders, etc.
Page 2 of 6
NO
CHILD 1
YES
NO
CHILD 2
YES
NO
CHILD 3
YES
NO

SN
13
14
15
16
17
18
QUESTIONS
Cardiovascular System
(i.e. stroke, cerebral ischemia,
rheumati c fever arthrosclerosis,
ischemic heart disease,
hypertension, heart valve disease,
irregular heart beat, pulmonary
embolism, phlebitis, etc.
Skin Subcutaneous Tissue
(i.e. dermatitis, acne, seborrhea,
purities, etc.)
Pregnancy, complication of
pregnancy, child birth and the
puerp erium
Mental Disorders
Infectious and parasitic diseases
Congenital anomalies, hereditary
diseases
20
Injury and poisoning
21
Previous medical / surgical

ho spitalization, procedures and
operations (if any)
23
24
25
26
SPOUSE
YES NO
Respiratory System (i.e.

sinusitis, allergi es,
tonsillitis/laryngitis, bronchitis,
emphysema, etc.
19
22
PRINCIPAL
YES NO
Have you ever been test ed positive

for HIV (AIDS) and for other
infectious disea ses (e.g. Hepatitis)
or Have any medical condition or
symptoms indicative of HIV
infection or AIDS?
Any diseases, symptoms and
complaints not mentioned above
Do you smoke? If yes, please
mention number per day.
Any family member for whom
insurance is not applied in this
application. (If yes, please provide
particulars of existing insurance
arrangements).
Have you ever undergone surgery
to remo ve a body organ or
structure? ( if yes, sp ecify body
organ/structure with date and
place of surgery)
Page 3 of 6
CHILD 1
YES NO
CHILD 2
YES NO
CHILD 3
YES NO

In case the answer is YES to any of the conditions/diseases above, please specify full details below.
Answers to Questions
(if answered as Yes)
Principal
Spouse
Child 1
Child 2
Child 3
Inherited disorder or genetic disease

Family Medical History
Cancer
(Father, Mother, Siblings)
Muscular Dystrophy
Have any member of your family had
Diabetes
symptoms or been diagnosed or received

treatment with respect to co nditions listed in
the side box?
Hemophilia
Multipl e Sclerosis
Nervous System / Sense Organ Disease
Illness of Cardiovascular System
Mental Illness or Disorder
Inherited disorder or genetic disease
Chronic Diseases:
A disease with one or more of the following characteristics: lasts 3 months or more, leaves residual disability, is caused by
non-reversible pathological alteration, req uires special training of the patient for rehabilitation, or may require a long
period of supervision, observation, or case.
Date:
(Signature over Printed Name)

PRINCIPAL
Page 4 of 6

DECLARATION:
I/We hereby declare with respect to both, myself and my dependants that to the best of my
knowledge and belief, the statement on application are full, true and correct and have
declared all material facts related to this application.
I/We understand that non-disclosure or misrepresentation of any material fact may invalidate
the quoted terms. I/We agree that all the documents issued in connection with the policy
shall be read together.
If my application gets accepted, I/We agree to be bound by the terms and conditions of
the policy. I/We hereby authorize any doctor, Hospital ,Clinic or Medical Provider, any
Insurance Company or any other Company, institution or any other person who has any
record or information about me and/or any of my family members to provider Dubai
National Insurance Company, with the complete information, including copies of their
records with reference to any sickness or accident, any treatment, examination, advice or
hospitalization or any other medical information required by Dubai National Insurance
Company..
The Coverage of Health Services provided by Dubai National Insurance Company is
described in the policy wording. By signing this for, I/We acknowledge that I/We read,
understood and agree to the terms and conditions as stated in the policy wording.
I/We agree that after acceptance of the quoted premiums in the quotation, I/We shall be
liable to pay all the premiums to Dubai National Insurance Company as per the specified
and selected plan of our choice.
Dubai National Insurance Company reserves the right to reject any authorization/claims
request for conditions (pre- existing, chronic) not declared by the applicant at the inception
of the policy.
Date:
Signature over Printed Name
Page 5 of 6

PRE-EXISTING DECLARATION FORM
I hereby understand and acknowledge that this plan will not cover any expenses
(consultation/tests/related conditions) until expiry of the policy, in respect to pre-existing
conditions that are not declared while at the initial purchase of insurance i.e. as at starting
from the enrolment date as per the following contract wording definition;
Pre-Existing Condition: Any Beneficiary health condition known and/or unknown to the
Beneficiary and/or to the Contract holder that may or may not have exhibited symptoms or
was a consequence of Injury or Illness for which medical, Surgical and/or pharmaceutical
Treatment, medical diagnosis or other advice was provided prior to the Beneficiarys
Enrollment Date.
I hereby relieve DNIRC from any liability related to this Clause.
Date:
Signature over Printed Name
Page 6 of 6

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Individual & Family Health Insurance

Proposal Form & Medical Questionnaires

Name of Plan Selected

If Yes, please provide

Individual & Family Health Insurance

Are you in good health and free from

Have you ever been declined for

Have you ever been accepted for

Do you involve yourself in any

Are you pregnant now? If Yes, when

Musculoskeletal &/or Connective

Individual & Family Health Insurance

Injury and poisoning

Previous medical / surgical

Respiratory System (i.e.

Have you ever been test ed positive

Individual & Family Health Insurance

Inherited disorder or genetic disease

(Father, Mother, Siblings)

Have any member of your family had

symptoms or been diagnosed or received

(Signature over Printed Name)

Individual & Family Health Insurance

Signature over Printed Name

Individual & Family Health Insurance

PRE-EXISTING DECLARATION FORM

I hereby relieve DNIRC from any liability related to this Clause.

Signature over Printed Name

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