MEDICAL

Name of Agent/ BDE/ Broker: Email:

‫ﻂ‬i‫ ﻞ‬/ ‫وﺳ‬i ‫اﻟﻮﻛ اﺳﻢ‬ Mobile No.

HEALTH DECLARATION FORM �� ‫اﻟﺼ اﻹﻗﺮار‬

‫اﺳﺘﻤﺎرة‬
Please note that: i ‫ اﻻﻧ��ﺎە إ� ﻣﺎ‬.�‫ﻳﺮ‬
•This Declaration form consists of three (3) pages, each page �‫ﺠﺐ ﻋ‬i ،‫) ﺻﻔﺤﺎت‬٣( ‫• �ﺗﺘﻜﻮن اﺳﺘﻤﺎرة اﻹﻗﺮار اﻟﻤﺎﺛﻠﺔ ﻣﻦ ﺛﻼث‬:
must be read and signed by the Main Applicant. �
‫ﻗﺮاءة �ﻞ ﺻﻔﺤﺔ واﻟﺘﻮﻗﻴﻊ‬ ‫اﻟﻄﻠﺐ‬��� ‫ﻣﻘﺪم‬‫اﻟﺮﺋ‬
• The application should accompany the following .‫ﻋﻠﻴﻬﺎ‬
documents: ‫ﺠﺐ أن ﻳﺮﻓﻖ �ﺎﻟﻄﻠﺐ اﻟﻮﺛﺎﺋﻖ‬ i•
a. Copy of passport with valid visa page, Copy of ‫�ة‬y ‫ﺴﺨﺔ ﻣﻦ ﺟﻮاز اﻟﺴﻔﺮ ﻣﻊ ﺻﻔﺤﺔ اﻟﺘﺄﺷ‬i (‫أ‬ :‫ﺔ‬i‫اﻟﺘﺎﻟ‬
Emirates ID .‫ﺔ‬i‫�ﺔ اﻹﻣﺎراﺗ‬i‫ﺴﺨﺔ ﻣﻦ اﻟﻬ‬i ،‫ﺔ‬i‫اﻟﺴﺎر‬ )
b. Proof of insurance (if any) ‫ )إن‬.� � ‫إﺛ�ﺎت اﻟﺘﺄﻣ‬ (‫ب‬
• Any alteration/ overwriting in the application must be . (‫ﺠﺐ أن ﻳﻮﻗﻊ) ﻣﻘﺪم وﺟﺪ‬i •
‫ﺎﻧﺎت‬i‫�اﺳ��ﺪال ﺑ‬y/ ‫اﻟﻄﻠﺐ ﻋ� أي ﺗﻐﻴ‬
signed by the applicant.
• False declarations shall render the insurance coverage ‫ ﻣﻊ‬،‫�ﺎن‬i‫ــــﺦ اﻟ‬i‫ﺔ ﻣﻦ ﺗﺎر‬iż‫ﺔ اﻟﺘﺄﻣﻴ‬i‫ � � اﻟﺘﻐﻄ‬. ‫• اﻹﻗﺮارات اﻟ�ﺎذ�ﺔ ﺗﻠ‬
invalid from the effective date, with no refund of premium.
� ‫ﻗﺴﻂ اﻟﺘﺄﻣ‬
. .
• NGI reserves the right to request medical evidence of ‫ﻃﻠﺐ إﺛ�ﺎت ﻃ‬ � ‫ﺔ ﻟﻠﺘﺄﻣﻴﻨﺎت اﻟﻌﺎﻣﺔ �ﺎﻟﺤﻖ‬i‫•�ﺗﺤﺘﻔﻆ اﻟ � ﻛﺔ اﻟﻮﻃﻨ‬.
�
insurability or reject any application aspercompany’s
..‫ ﻟﺪى اﻟ ��ﻛﺔ‬.��� ‫ أو رﻓﺾ أي ﻃﻠﺐ ﺣﺴﺐ إرﺷﺎدات اﻟﺘﺄﻣ‬.� � ‫ﺔ اﻟﺘﺄﻣ‬i‫ﺎﻧ‬r‫إﻣ‬
underwriting guidelines (‫ﺠﺐ ﻋ� ﻣﻘﺪم اﻟﻄﻠﺐ اﻟﺮﺋ� �� اﻹﺟﺎ�ﺔ ﻋﻦ اﻷﺳﺌﻠﺔ ﻣﻦ اﻟﻔﺼﻞ )أ‬i •
Main Applicant shall answer the questions from
• ‫ﻞ‬i‫ﺗﺘﻀﻤﻦ ﻗﺴﻢ ﺗﻔﺎﺻ‬ � � ‫ﻟﺸﺨﺼﻪ وﻟﺠﻤﻴﻊ أﻓﺮاد اﻷ�ة اﻟ‬‫إ� اﻟﻔﺼﻞ‬ (‫)د‬
Chapter (A) to Chapter (D) for himself and for all Family ‫�ﺠﺐ ﻋ� ﻣﻘﺪم اﻟﻄﻠﺐ‬ i ‫ ﺻﻔﺤﺎت‬٥ �‫• ﺗﺤﺘﻮي ﻫﺬە اﻻﺳﺘﻤﺎرة ﻋ‬
Members that includes Detail of Answers section. ‫ﺔ‬i‫ اﻻﺳﺘﻤﺎرة ﻻﻏ‬.y ‫اﻹﺟﺎ�ﺔ ﻋﻠﻴﻬﺎ وﺗﻮﻗﻴﻊ ﺟﻤﻴﻊ اﻟﺼﻔﺤﺎت و�ﻻ ﺳﺘﻌﺘ‬
• This form contains 5 pages that the applicant must

APPLICANT’S INFORMATION ‫اﻟﻄﻠﺐ ﻣﻘﺪم‬

‫ﺎﻧﺎت‬i‫ﺑ‬
Full Name (First, Middle and Family): ‫اﻻﺳﻢ �ﺎﻟ�ﺎﻣﻞ )اﻷول واﻷوﺳﻂ‬
(:‫واﻟﻌﺎﺋﻠﺔ‬
Occupation: :‫اﻟﻤﻬﻨﺔ‬

Marital Status: :‫ﺔ‬i‫اﻟﺤﺎﻟﺔ اﻻﺟﺘﻤﺎﻋ‬

Gender: Height (Cm): Weight (Kg): (:‫اﻟﻮزن )ﻛﻐﻢ‬ ‫اﻟﻄﻮل‬ :‫ﺲ‬ż‫اﻟﺠ‬

(:‫)ﺳﻢ‬
Nationality: :‫ﺔ‬i‫ﺴ‬ż‫اﻟﺠ‬

Form
Date of Birth: (day/month/year) (‫ﺳﻨﺔ‬/‫ﺷﻬﺮ‬/‫ )ﻳﻮم‬:‫ﻼد‬i‫ــــﺦ اﻟﻤ‬i‫ﺗﺎر‬

Employer: :‫ﺻﺎﺣﺐ اﻟﻌﻤﻞ‬ Health Declaration

Place of Visa Issuance: :‫�ة‬y ‫ﺎن إﺻﺪار اﻟﺘﺄﺷ‬r‫ﻣ‬

Mobile Number: :‫رﻗﻢ اﻟﻬﺎﺗﻒ اﻟﻤﺘﺤﺮك‬

Email: :�� . ‫و‬y� ‫ﻜ‬i ‫اﻹﻟ ﺪ‬iy. ‫اﻟ‬

Mailing Address: :‫ﺪي‬.iy ‫اﻟﻌﻨﻮان اﻟ‬

City: P.O.Box: :‫ب‬.‫ص‬ :‫اﻟﻤﺪﻳﻨﺔ‬

Your Current Health Insurance Provider :‫ اﻟﺼ �� اﻟﺤﺎ � � اﻟﺨﺎص �ﻚ‬.� � ‫ﻣﺰود اﻟﺘﺄﻣ‬

Expiry Date :‫ﺔ‬i‫ــــﺦ اﻧﺘﻬﺎء اﻟﺼﻼﺣ‬i‫ﺗﺎر‬

If Previously Insured, please provide Certificate of Continuity OR Certificate of Insurance and Card Copies.
�
.‫ﺴﺦ ﻣﻦ اﻟ�ﻄﺎﻗﺔ‬i ‫ و‬.� � ‫ﺔ أو ﺷﻬﺎدة ﺗﺄﻣ‬i‫ﻢ ﺷﻬﺎدة اﺳﺘﻤﺮار‬i‫� ﺗﻘﺪ‬y . � ‫ ﻓ‬،‫ﻚ ﺳﺎ� ﻘﺎ‬i‫ ﻋﻠ‬.� � ‫ � � ﺣﺎل اﻟﺘﺄﻣ‬.
 MEDICAL

MEMBERS’ SCHEDULE ‫اﻷﻋﻀﺎء‬

‫ﺟﺪول‬
Date of Birth
S. No. Name Relationship (dd-mm-yyyy) Height (Cm) Weight (Kg)
‫ م‬.‫ر‬ ‫اﻻﺳﻢ‬ ‫اﻟﻌﻼﻗ‬ ‫ﻼد‬i‫ــــﺦ اﻟﻤ‬i‫ﺗﺎر‬ ) ‫اﻟﻄﻮل‬ (‫اﻟﻮزن )ﻛﻐﻢ‬
‫ﺔ‬ (‫ﺳﻨﺔ‬/‫ﺷﻬﺮ‬/‫)ﻳﻮم‬ (‫ﺳﻢ‬

The following Health Questionnaire are applicable to named applicants in this form.
�
.‫ﺎن اﻟﺼ �� اﻟﺘﺎ � � ﻋ� ﻣﻘﺪ � � اﻟﻄﻠﺐ اﻟﻤﺬﻛﻮر�ﻦ � � ﻫﺬە اﻻﺳﺘﻤﺎرة‬i‫ﻳﻨﻄﺒﻖ اﻻﺳ�ﺒ‬

CHAPTER A - HEALTH QUESTIONNAIRE ‫ﺎن‬i‫اﻟﻔﺼﻞ )أ( اﺳ�ﺒ‬

‫اﻟﺼﺤﺔ‬
Specific Medical History (if "Yes," specify diagnostic details, Yes No ‫ﻞ‬i‫ ﺣﺪد ﺗﻔﺎﺻ‬،"‫ � � ﻣﺤﺪد )إذا �ﺎﻧﺖ اﻹﺟﺎ�ﺔ "ﻧﻌﻢ‬.‫ﺗﺎر�ــــﺦ ﻃ‬
�
treatment received & recovery status) ‫ﻧﻌ‬ ‫ﻻ‬ � � ( ‫ﻪ وﺣﺎﻟﺔ اﻟﺘﻌﺎ‬i‫ﺺ واﻟﻌﻼج اﻟﺬي ﺗﻢ ﺗﻠﻘ‬i‫اﻟ�ﺸﺨ‬
‫ﻢ‬
1. Have you ever been diagnosed, treated or felt any ‫ﺼﻚ أو ﻋﻼﺟﻚ أو ﺷﻌﺮت �ﺄي‬i‫ ﻫﻞ ﺗﻢ �ﺸﺨ‬1-
disorder, pain or had any symptoms related to � ‫ﻚ أي أﻋﺮاض ﻣﺮﺗ�ﻄﺔ �ﻤﺎ‬i‫ أو أﻟﻢ أو ﻇﻬﺮت ﻋﻠ‬ṿ‫اﺿﻄﺮا‬
A. Musculoskeletal & /or Connective Tissue System?
(i.e.: fractures, joint or cartilage problems, back problems, �� :
:‫ﺴﺠﺔ اﻟﻀﺎﻣﺔ؟ )ﻣﺜﻞ‬i‫أو ﻧﻈﺎم اﻷ‬/‫ � � و‬ri‫اﻟﺠﻬﺎز اﻟﻌﻀ � � اﻟﻬ‬ ( ‫)أ‬
deformities, bone infections, osteoporosis, arthritis, ‫ ﻣﺸﺎ�ﻞ‬،‫اﻟ�ﺴﻮر‬
rheumatism, sports injury etc.) OR ‫ اﻟﺘﻬﺎ�ﺎت‬،‫ اﻟ�ﺸﻮﻫﺎت‬،‫ ﻣﺸﺎ�ﻞ اﻟﻈﻬﺮ‬،‫ﻒ‬i‫اﻟﻤﻔﺎﺻﻞ أو اﻟﻐﻀﺎر‬
any related symptoms/conditions not mentioned above ‫ اﻹﺻﺎ�ﺎت اﻟ‬،‫م‬.y � ‫ اﻟﺮوﻣﺎﺗ‬،‫ اﻟﺘﻬﺎب اﻟﻤﻔﺎﺻﻞ‬،‫ ﻫﺸﺎﺷﺔ اﻟﻌﻈﺎم‬،‫اﻟﻌﻈﺎم‬
‫� ﻣﺬﻛﻮرة‬y ‫ ﺣﺎﻻت ذات ﺻﻠﺔ ﻏ‬/ ‫ وﻣﺎ ﺷﺎ�ﻪ ذﻟﻚ( أو أي أﻋﺮاض‬،‫ﺔ‬i‫ﺎﺿ‬is

Form
‫أﻋﻼە‬
�
B. Cancer, Neoplasms, Tumors? ‫ اﻟ�ﻃﺎن واﻷورام؟ )ﺣﺪد اﻟﻨ�ع واﻟﻤﻮﻗﻊ واﻟﻌﻼج وﺳﻮاء �ﺎن ﺧﺒ� ﺜﺎ أو‬- ‫ب‬
�
(Specify type, location, treatment, whether malignant or benign) (‫ ﺪا‬i‫ﺣﻤ‬

C. Blood & Blood Forming Organ Systems?

‫ ﻓﻘﺮ‬:‫�ﻞ اﻟﻤﺜﺎل‬i‫ أﻧﻈﻤﺔ اﻟﺪم واﻷﻋﻀﺎء اﻟﻤﻜﻮﻧﺔ ﻟﻠﺪم؟ )ﻋ� ﺳ‬-‫ج‬
Health Declaration
(i.e.: anemia, thalassemia, bleeding disorders, blood cell disease, .
،‫ﺎ اﻟﺪم‬i‫ ﻣﺮض ﺧﻼ‬،‫ﻒ‬.iy ‫ اﺿﻄﺮا�ﺎت اﻟ‬،�� ‫ ﻓﻘﺮ اﻟﺪم اﻟ�ﻮ‬،‫اﻟﺪم‬
spleen problems, lymph node problems, etc.) OR any related
‫ وﻣﺎ ﺷﺎ�ﻪ ذﻟﻚ( أو أي أﻋﺮاض‬،‫ﺔ‬i‫ﻤﻔﺎو‬i‫ ﻣﺸﺎ�ﻞ اﻟﻌﻘﺪ اﻟﻠ‬،‫ﻣﺸﺎ�ﻞ اﻟﻄﺤﺎل‬
symptoms/conditions not mentioned above ‫� ﻣﺬﻛﻮرة أﻋﻼە‬y ‫ ﺣﺎﻻت ذات ﺻﻠﺔ ﻏ‬/

D. Digestive System? ‫ ا‬- ‫ ﻋﺪوى‬- ‫�ﻒ‬i‫ ﻧ‬،‫ ﻗﺮﺣﺔ اﻟﻤﻌﺪة‬،‫اﻟﺠﻬﺎز اﻟﻬﻀ ��؟ )ﻣﺜﻞ اﻻرﺗﺠﺎع‬ -‫د‬
(i.e. reflux, ulcers, bleeding-infection-obstruction- perforation of ‫ ﻣﺸﺎ�ﻞ‬،‫ أو اﻷﻣﻌﺎء أو اﻟﻘﻮﻟﻮن‬،‫ أو اﻟﻤﻌﺪة‬،‫ اﻧﺜﻘﺎب اﻟﻤﺮيء‬- ‫ﺴﺪاد‬i
‫ اﻷورام‬،‫ﺎس‬is‫ اﻟﻤﺮارة أو اﻟﺒﻨﻜ‬،‫ ﻣﺸﺎ�ﻞ اﻟ��ﺪ‬،‫اﻟﻔﻚ‬/‫اﻟﻔﻢ‬/‫اﻟﻠﺜﺔ‬/‫اﻷﺳﻨﺎن‬
the esophagus, stomach, intestines or colon, problems of the .
teeth/gums/mouth/jaw, problems with the liver, gallbladder or �y ‫ ﺣﺎﻻت ذات ﺻﻠﺔ ﻏ‬/ ‫ﻢ؟ أو أي أﻋﺮاض‬i‫ � � اﻟﻤﺴﺘﻘ‬/‫ﺔ‬i‫ﺪة اﻟ ��ﺟ‬i‫اﻟﺤﻤ‬
pancreas, anal/rectal polyps? OR any related ‫ﻣﺬﻛﻮرة أﻋﻼە‬
symptoms/condition not mentioned above
�
E. Endocrine, Nutritional, Metabolic and/or Immune System? ‫أو‬/‫ﻞ اﻟﻐﺬا � � و‬i‫أو اﻟﺘﻤﺜ‬/‫ﺔ و‬i‫أو اﻟﺘﻐﺬ‬/‫ﺟﻬﺎز اﻟﻐﺪد اﻟﺼﻤﺎء و‬ -‫ه‬
(i.e. diabetes, thyroid or pituitary gland problems, adrenal gland, ‫ﺔ أو اﻟﻐﺪة اﻟﻨﺨﺎﻣ‬i‫ ﻣﺸﺎ�ﻞ اﻟﻐﺪة اﻟﺪرﻗ‬،‫اﻟﻤﻨﺎﻋﺔ؟ )ﻣﺜﻞ ﻣﺮض اﻟﺴﻜﺮي‬
ovary or testes problems, hormone problems, gout, multiple ،.� � ‫ﺾ أو اﻟﺨﺼ�ﺘ‬i‫ ﻣﺸﺎ�ﻞ اﻟﻤﺒ‬،‫ﺔ‬is‫ ﻣﺸﺎ�ﻞ اﻟﻐﺪة اﻟ�ﻈ‬،‫ﺔ‬i
sclerosis, cystic fibrosis, metabolic disorders, immune problems, ،�� ��‫ﻒ اﻟ‬i‫ اﻟﺘﻠ‬،‫ اﻟﺘﺼﻠﺐ اﻟﻤﺘﻌﺪد‬،‫ اﻟﻨﻘﺮس‬،‫ﻣﺸﺎ�ﻞ اﻟﻬﺮﻣﻮﻧﺎت‬
etc.) OR any related symptoms/conditions not mentioned above �
‫ وﻣﺎ ﺷﺎ�ﻪ ذﻟﻚ( أو أي‬،‫ ﻣﺸﺎ�ﻞ اﻟﻤﻨﺎﻋﺔ‬،�� ‫ﻞ اﻟﻐﺬا‬i‫اﺿﻄﺮا�ﺎت اﻟﺘﻤﺜ‬
‫� ﻣﺬﻛﻮرة أﻋﻼە‬y ‫ﺣﺎﻻت ذات ﺻﻠﺔ ﻏ‬/‫أﻋﺮاض‬
MEDICAL
 MEDICAL

F. Nervous System or Sense Organs?

،‫ واﻟﺪوار‬،‫ﻋﺪوى اﻷذن‬/‫ � � أو اﻟﺤﻮاس؟ )ﻣﺜﻞ إﺻﺎ�ﺔ‬.‫اﻟﺠﻬﺎز اﻟﻌﺼ‬ -‫و‬
(i.e. ear injury/infection, vertigo, hearing problems, eye ‫وﻣﺸﺎ�ﻞ‬
injury/disease, retina problems, glaucoma, vision problems, .
‫ وﻣﺸﺎ�ﻞ اﻟﺮؤ‬،‫ واﻟﺰرق‬،‫ﺔ‬i‫ وﻣﺸﺎ�ﻞ اﻟﺸ�ﻜ‬، � � ‫ﻣﺮض اﻟﻌ‬/‫ و�ﺻﺎ�ﺔ‬،‫اﻟﺴﻤﻊ‬
muscular dystrophy, brain/nerve degeneration, meningitis, ،‫ﺎ‬i‫ واﻟﺘﻬﺎب اﻟﺴﺤﺎ‬،‫اﻷﻋﺼﺎب‬/‫ وﺗﻨﻜﺲ اﻟﺪﻣﺎغ‬،‫ وﺿﻤﻮر اﻟﻌﻀﻼت‬،‫ﺔ‬i
paralysis, seizures, epilepsy, neuralgia, etc.) OR any related ،‫ واﻟﻨ��ﺎت‬،‫واﻟﺸﻠﻞ‬
symptoms/conditions not mentioned above
‫ﺣﺎﻻت ذات‬/‫ وﻣﺎ ﺷﺎ�ﻪ ذﻟﻚ( أو أي أﻋﺮاض‬،�� .‫ واﻷﻟﻢ اﻟﻌﺼ‬،‫واﻟ�ع‬
‫� ﻣﺬﻛﻮرة أﻋﻼە‬y ‫ﺻﻠﺔ ﻏ‬
G. Genitourinary System?
‫ واﻟﻔﺸﻞ‬،‫��اﻟﻤﺜﺎﻧﺔ‬/‫اﻟﺠﻬﺎز اﻟﺒﻮ � � اﻟﺘﻨﺎﺳ ��؟ )ﻣﺜﻞ اﻟﺘﻬﺎ�ﺎت اﻟ‬ -‫ز‬
(i.e. kidney/bladder infections, renal failure, kidney stones,
،‫ﺔ‬is‫ وﻣﺸﺎ�ﻞ اﻟﺪورة اﻟﺸﻬ‬،‫ واﻧ��ﺎذ �ﻄﺎﻧﺔ اﻟﺮﺣﻢ‬،��‫ وﺣﺼﻮات اﻟ‬،‫اﻟ�ﻠﻮي‬
endometriosis, menstrual cycle problems, ovarian cysts, prostate ،‫ﺾ‬i‫وﺗﻜ�ﺴﺎت اﻟﻤﺒ‬
problems, testicle infections, sperm abnormalities, fertility
،‫�ﺔ‬i‫ و�ﺸﻮﻫﺎت اﻟﺤﻴﻮاﻧﺎت اﻟﻤﻨ‬،‫ﺔ‬i‫ واﻟﺘﻬﺎ�ﺎت اﻟﺨﺼ‬،‫وﺳﺘﺎﺗﺎ‬.y ‫وﻣﺸﺎ�ﻞ اﻟ‬
problems, etc. OR any related symptoms/conditions not
mentioned above �y ‫ﺣﺎﻻت ذات ﺻﻠﺔ ﻏ‬/‫ وﻣﺎ ﺷﺎ�ﻪ ذﻟﻚ أو أي أﻋﺮاض‬،‫وﻣﺸﺎ�ﻞ اﻟﺨﺼ��ﺔ‬
‫ﻣﺬﻛﻮرة أﻋﻼە‬
H. Respiratory System?
‫ﺔ‬i‫ﺔ واﻟﺤﺴﺎﺳ‬i‫اﻟﺠﻬﺎز اﻟﺘﻨﻔ ��؟ )ﻣﺜﻞ اﻟﺘﻬﺎب اﻟﺠﻴﻮب اﻷﻧﻔ‬ -‫ح‬
(i.e. sinusitis, allergies, tonsillitis/laryngitis, bronchitis,
emphysema, pneumonia, etc.) OR any related ‫ﺔ واﻧﺘﻔﺎخ‬i‫اﻟﺘﻬﺎب اﻟﺤﻨﺠﺮة واﻟﺘﻬﺎب اﻟﺸﻌﺐ اﻟﻬﻮاﺋ‬.�/ � ‫واﻟﺘﻬﺎب اﻟﻠﻮزﺗ‬
‫اﻟﺮﺋﺔ واﻻﻟﺘﻬﺎب اﻟﺮﺋﻮي‬
symptoms/conditions not mentioned above ‫� ﻣﺬﻛﻮرة أﻋﻼە‬y ‫ ﺣﺎﻻت ذات ﺻﻠﺔ ﻏ‬/ ‫وﻣﺎ إ� ذﻟﻚ( أو أي أﻋﺮاض‬
I. Cardiovascular System? ‫ ﻧﻘﺺ‬،‫ﺔ‬i‫�ﺔ؟ )ﻣﺜﻞ اﻟﺴﻜﺘﺔ اﻟﺪﻣﺎﻏ‬i‫ﺔ اﻟﺪﻣ‬i‫ﻧﻈﺎم اﻟﻘﻠﺐ واﻷوﻋ‬ -‫ط‬
�
(i.e. stroke, cerebral ischemia, rheumatic fever, atherosclerosis, ‫ﺔ‬i‫ و‬y ‫اﻟ‬
aneurysm, embolism, peripheral vascular disease, hypertension, ‫ اﻻ‬،‫�ﺔ‬i‫ﺔ اﻟﺪﻣ‬i‫ ﺗﻤﺪد اﻷوﻋ‬،.� � ‫ ﺗﺼﻠﺐ اﻟ ��اﻳ‬،‫ﺔ‬i‫ﻣ‬.y � ‫ اﻟﺤ� اﻟﺮوﻣﺎﺗ‬،‫ﺔ‬i‫اﻟﺪﻣﺎﻏ‬
heart valve disease, irregular heartbeat, pulmonary embolism, ،‫ ارﺗﻔﺎع ﺿﻐﻂ اﻟﺪم‬،‫ﺔ‬i‫�ﺔ اﻟﻄﺮﻓ‬i‫ﺔ اﻟﺪﻣ‬i‫ أﻣﺮاض اﻷوﻋ‬،‫ﺴﺪاد اﻟﺪﻣﻮي‬i
phlebitis, varicosities, Ischemic Heart Disease etc.) OR any ،‫أﻣﺮاض ﺻﻤﺎم اﻟﻘﻠﺐ‬
related symptoms/conditions not mentioned above ،�� ‫ اﻟﺪوا‬،‫ﺪي‬i‫ اﻻﻟﺘﻬﺎب اﻟﻮر‬،‫ﺴﺪاد اﻟﺮﺋﻮي‬i‫ اﻻ‬،‫ﺎت اﻟﻘﻠﺐ‬.�� ‫ﻋﺪم اﻧﺘﻈﺎم‬
‫ ﺣﺎﻻت ذات ﺻﻠﺔ ﻏ‬/ ‫ﺔ وﻣﺎ إ� ذﻟﻚ( أو أي أﻋﺮاض‬i‫أﻣﺮاض اﻟﻘﻠﺐ اﻹﻗﻔﺎر‬
‫� ﻣﺬﻛﻮرة أﻋﻼە‬y
J. Skin-Subcutaneous Tissue? ‫ ﺣﺐ‬،‫ اﻟﺘﻬﺎب اﻟﺠﻠﺪ‬،‫�ﻞ اﻟﻤﺜﺎل‬i‫ﺴﺠﺔ ﺗﺤﺖ اﻟﺠﻠﺪ؟ )ﻋ� ﺳ‬i‫ اﻷ‬-‫ي‬
(i.e. dermatitis, acne, seborrhea, puritis,etc.) OR any related ‫ ﺣﺎﻻت ذات ﺻﻠﺔ ﻏ‬/ ‫ وﻣﺎ إ� ذﻟﻚ( أو أي أﻋﺮاض‬،‫ اﻟﺤﻜﺔ‬،‫ اﻟﺰﻫﻢ‬،‫اﻟﺸ�ﺎب‬
symptoms/conditions not mentioned above ‫� ﻣﺬﻛﻮرة أﻋﻼە‬y
2. Have you ever undergone surgery to remove a body ‫ﺔ ﻹزاﻟﺔ ﻋﻀﻮ أو ﺑ‬i‫ﺔ ﺟﺮاﺣ‬i‫ ﻫﻞ ﺳﺒﻖ ﻟﻚ أن ﺧﻀﻌﺖ ﻟﻌﻤﻠ‬2-
organ or structure? ‫ ﺗﺎر�ــــﺦ وﻣ�ﺎن‬،‫ﻞ اﻟﺠﺴﻢ‬i�‫�ﺔ ﻣﻦ اﻟﺠﺴﻢ؟ )ﺣﺪد ﻋﻀﻮ � ﻫ‬i
(Specify body organ/ Structure, date & place of surgery?) (‫اﻟﺠﺮاﺣﺔ؟‬

3. Are you HIV positive or have any medical condition or ‫ �ﻔ ��وس ﻧﻘﺺ اﻟﻤﻨﺎﻋﺔ اﻟ� ��ي أو‬ṿ‫ﻫﻞ أﻧﺖ ﻣﺼﺎ‬ 3-

Form
symptom indicative of HIV infection or AIDS? ‫ﺔ أو أﻋﺮاض ﺗﺪل ﻋ� اﻹﺻﺎ�ﺔ �ﻔ ��وس ﻧﻘﺺ‬i‫ﻟﺪ�ﻚ أي ﺣﺎﻟﺔ ﻃﺒ‬
‫اﻟﻤﻨﺎﻋﺔ اﻟ� ��ي أو اﻹ�ﺪز؟‬

4. Do you or your family member members have any history ‫ ﻫﻞ ﻟﺪ�ﻚ أﻧﺖ أو أﺣﺪ أﻓﺮاد ﻋﺎﺋﻠﺘﻚ أي ﺗﺎر�ــــﺦ إﺻﺎ�ﺔ �ﻔ‬4-
of Covid-19, please specify? ‫ اﻟﺘﺤﺪ�ﺪ؟‬.�‫ ﻳﺮ‬،-19‫ﺪ‬i‫��وس ﻛﻮﻓ‬
Health Declaration
5. If you or your family members are on medications, please .� � � ‫ ﻓ‬،‫ إذا ﻛﻨﺖ أﻧﺖ أو أﻓﺮاد ﻋﺎﺋﻠﺘﻚ ﺗﺘﻌﺎﻃﻮن اﻷدو�ﺔ‬5-
�
specify with the dose and the frequency in the below section ‫ﺗﺤﺪ�ﺪ اﻟﺠﺮﻋﺔ واﻟﻮﺗ ��ة � � اﻟﻘﺴﻢ اﻟﻮارد أدﻧﺎە ﻟﻠﻤﻌﻠﻮﻣﺎت‬
of additional informationCovid-19, please specify? ‫ﺔ‬i‫اﻹﺿﺎﻓ‬

CHAPTER B - FAMILY HEALTH BACKGROUND ‫ة‬s‫ﺔ ﺻﺤﺔ اﻷ‬i‫ ﺧﻠﻔ‬ṿ - ‫اﻟﻔﺼﻞ‬

Family Medical History (father, mother, siblings) Has any .
‫ اﻷﺷﻘﺎء( ﻫﻞ ﻋﺎ � أي‬،‫ اﻷم‬،ṿ‫ � � ﻟﻠﻌﺎﺋﻠﺔ )اﻷ‬.‫اﻟﺘﺎر�ــــﺦ اﻟﻄ‬
member of your family had symptoms or been diagnosed or � � �
،‫ﻋﻼ ﺟﺎ �ﺴ�ﺐ‬ � ‫ﺼﻪ أو ﺗﻠ‬i‫ﻓﺮد ﻣﻦ أﻓﺮاد ﻋﺎﺋﻠﺘﻚ أﻋﺮا ﺿﺎ أو ﺗﻢ �ﺸﺨ‬
received treatment for, including but not limited to Inherited � .
‫ اﻻﺿﻄﺮاب اﻟﻮرا � � أو اﻟﻤﺮض‬،�‫�ﻞ اﻟﻤﺜﺎل ﻻ اﻟﺤ‬i‫�ﻤﺎ � � ذﻟﻚ ﻋ� ﺳ‬
disorder or genetic disease, Hemophilia, Multiple Sclerosis, ‫ﻨﺎﻋﻮر‬ �
‫ اﻟﺘﺼﻠﺐ‬،( ‫ﺎ )اﻟ‬i‫ﻠ‬i‫ﻤﻮﻓ‬i‫ اﻟﻬ‬،�� ‫اﻟﻮرا‬
Cancer, Mental Illness, Disorder of the Cardio-Vascular ‫ﺔ اﻟﺪﻣ‬i‫ اﺿﻄﺮاب ﻧﻈﺎم اﻟﻘﻠﺐ واﻷوﻋ‬،�� ‫ اﻟﻤﺮض اﻟﻌﻘ‬،‫ اﻟ�ﻃﺎن‬،‫اﻟﻤﺘﻌﺪد‬
‫�ﺔ أو ﻣﺮض‬i
System, Diabetes or any other chronic illness.
.‫اﻟﺴﻜﺮي أو أي ﻣﺮض ﻣﺰﻣﻦ آﺧﺮ‬

CHAPTER C - MEMBER HEALTH ROUTINE ‫ ج روﺗ � � � ﺻﺤﺔ اﻷﻋﻀﺎء‬- ‫اﻟﻔﺼﻞ‬

Profile (if answer Yes is selected, specify details and numbers) ‫ﻞ‬i‫ ﺣﺪد اﻟﺘﻔﺎﺻ‬،‫اﻟﻤﻠﻒ اﻟﺸﺨ �� )إذا ﺗﻢ ﺗﺤﺪ�ﺪ اﻹﺟﺎ�ﺔ ﻧﻌﻢ‬
(‫واﻷرﻗﺎم‬
1. Do you smoke?
‫ ﻓﻤﺎذا ﺗﺪﺧﻦ؟ واﻟﻌﺪد اﻟﻴﻮ‬،"‫ﻫﻞ ﺗﺪﺧﻦ؟ )إذا �ﺎﻧﺖ اﻹﺟﺎ�ﺔ "ﻧﻌﻢ‬ 1-
(if Yes, what do you smoke? and number per day)
� (
�
 MEDICAL
2. Do you practice any kind of routine exercise? ‫ﻦ اﻟﻤﻨﺘﻈﻤﺔ؟‬i‫ﻫﻞ ﺗﻤﺎرس أي ﻧ�ع ﻣﻦ اﻟﺘﻤﺎر‬ 2-
 MEDICAL

CHAPTER D - FAMILY PLANNING (FEMALE ONLY) (‫ة )ﻓﻘﻂ ﻟﻺﻧﺎث‬s‫اﻷ ﻢ‬i ‫ﺗﻨﻈ‬
‫ اﻟﻔﺼﻞ‬- ‫د‬
Maternity/ History of Conception (if answer Yes is selected,
‫ ﺣﺪد‬،‫اﻷﻣﻮﻣﺔ � ﺗﺎر�ــــﺦ اﻟﺤﻤﻞ )إذا ﺗﻢ ﺗﺤﺪ�ﺪ اﻹﺟﺎ�ﺔ ﻧﻌﻢ‬
specify details and numbers) (‫ﻞ واﻷرﻗﺎم‬i‫اﻟﺘﻔﺎﺻ‬

1. Are you pregnant now? if Yes, Please specify Expected Date ‫ﺪ ﺗﺎر‬i‫ ﺗﺤﺪ‬.�‫ ﻳﺮ‬،‫ ﻫﻞ أﻧِﺖ ﺣﺎﻣﻞ اﻵن؟ إذا �ﺎﻧﺖ اﻹﺟﺎ�ﺔ ﺑﻨﻌﻢ‬1-
Delivery ‫ﻫﻞ �ﺎﻧﺖ ﻫﻨﺎك‬ ‫ــــﺦ اﻟﻮﻻدة اﻟﻤﺘﻮﻗﻊ‬i
Have there been any complication to date? ‫أي ﻣﻀﺎﻋﻔﺎت ﺣ �� اﻵن؟‬

2. Last Menstrual Period ‫ﺔ‬is‫آﺧﺮ دورة ﺷﻬ‬ -2

3. Are you currently trying to get pregnant? ‫�ﺎ؟‬i ‫ اﻟﺤﻤﻞ ﺣﺎﻟ‬.� � ‫ﻫﻞ ﺗﺤﺎوﻟ‬ -3

4. Are you undergoing any form of fertility treatment? ‫ﺎل ﻋﻼج اﻟﻌﻘﻢ؟‬r‫ﻞ ﻣﻦ أﺷ‬r‫ ﻷي ﺷ‬.� � ‫ﻫﻞ ﺗﺨﻀﻌ‬ -4

.
5. If currently not pregnant, when did you last conceive? ‫ﺪ‬i‫ ﺗﺤﺪ‬.�‫ ﻓﻤ � � ﺣﻤﻠﺖ آﺧﺮ ﻣﺮة؟ )ﻳﺮ‬،‫�ﺎ‬i ‫� � ﺣﺎل ﻋﺪم ﺣﻤﻠﻚ ﺣﺎﻟ‬ -5
(Please specify Date) (‫ــــﺦ‬i‫اﻟﺘﺎر‬

6. What was the outcome of last conception/pregnancy? (Specify ‫ﺔ‬i‫ﻌ‬i‫ وﻻدة ﻃﺒ‬/ ‫ﺪ؛ إﺟﻬﺎض‬i‫ اﻟﺘﺤﺪ‬.�‫�ﺠﺔ آﺧﺮ ﺣﻤﻞ؟ )ﻳﺮ‬i‫ﻣﺎذا �ﺎﻧﺖ ﻧ‬ 6-
Abortion/ Normal Delivery/Operative Delivery) (‫ﺔ‬i‫ وﻻدة ﺟﺮاﺣ‬/

7. Do you have any history of complication during the pregnancy? ‫ــــﺦ ﻣﻦ اﻟﻤﻀﺎﻋﻔﺎت أﺛﻨﺎء اﻟﺤﻤﻞ؟‬i‫ﻚ أي ﺗﺎر‬i‫ﻫﻞ ﻟﺪ‬ -7

DETAIL OF ANSWERS ‫ﺎت�اﻹﺟﺎ ﻞ‬i

‫ ﺗﻔﺼ‬Please 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."
.
‫ﺪ رﻗﻢ اﻟﻌﻀﻮ أًو� �ﻤﺎ ﻫﻮ ﻣﺬﻛﻮر � � ﺟﺪول اﻷﻋﻀﺎء واﻟﻔﺼﻞ ورﻗﻢ‬i‫ﻪ "ﻧﻌﻢ" ﻣﻦ ﺧﻼل ﺗﺤﺪ‬i‫ﻞ ﻋﻦ أي ﺳﺆال إذا �ﺎﻧﺖ اﻹﺟﺎ�ﺔ ﻋﻠ‬i‫ﻢ ﺗﻔﺎﺻ‬i‫ ﺗﻘﺪ‬.�‫ﻳﺮ‬
‫اﻟﺴﺆال‬
‫ اﻟﺘﻮﺿﻴﺢ‬-3:‫"ج‬2- :‫�ﻞ اﻟﻤﺜﺎل‬i‫ ﻋ� ﺳ‬.‫ﻞ اﻟﺘﻮﺿﻴﺢ‬i‫"وﺗﻔﺎﺻ‬.

EXPLANATION
‫اﻟﺘﻮﺿﻴﺢ‬
Member No. Chapter No. Question No.

Form
Type of Disorder Date of Onset Details of Present Status
‫رﻗﻢ اﻟﻌﻀﻮ‬ ‫رﻗﻢ اﻟﻔﺼﻞ‬ ‫رﻗﻢ اﻟﺴﺆال‬ dd-mm-yyyy Treatment Health of
‫ﻧ�ع اﻻﺿﻄﺮاب‬
‫ــــﺦ اﻹﺻﺎ�ﺔ‬i‫ﺗﺎر‬ ‫ﻞ‬i‫ﺗﻔﺎﺻ‬ ‫ﺣﺎﻟﺔ اﻟﺼﺤﺔ اﻟﺤﺎﻟ‬
(‫ﺳﻨﺔ‬/‫ﺷﻬﺮ‬/‫)ﻳﻮم‬
‫اﻟﻌﻼج‬ ‫ﺔ‬i
Health Declaration

ADDITIONAL INFORMATION ‫ﺔ‬i ‫إﺿﺎﻓ‬

‫ﻣﻌﻠﻮﻣﺎت‬
 MEDICAL

DECLARATION & AUTHORIZATION: (‫ة )ﻓﻘﻂ ﻟﻺﻧﺎث‬s‫اﻷ ﻢ‬i‫ﺗﻨﻈ د‬

‫ اﻟﻔﺼﻞ‬-
As no list of questions can be exhaustive I hereby declare that
what has been stated above information pertaining to myself ‫ ﻓﺄﻧﺎ أﻗﺮ‬،‫�ﻤﺎ أﻧﻪ ﻻ ﺗﻮﺟﺪ ﻗﺎﺋﻤﺔ ﻣﻦ اﻷﺳﺌﻠﺔ �ﻤﻜﻦ أن ﺗﻜﻮن ﺷﺎﻣﻠﺔ‬
and my dependents is true and complete to the best of my � � . ‫�ﻤﻮﺟ�ﻪ �ﺄن اﻟﻤﻌﻠﻮﻣﺎت اﻟﻤﺬﻛﻮرة أﻋﻼە اﻟﻤﺘﻌﻠﻘﺔ‬
knowledge and belief and I have not withheld any material
information and I will tell NGI immediately if any of the ‫ﺤﺔ و�ﺎﻣﻠﺔ ﻋ� ﺣﺪ‬i‫و�ﻤﻦ أﻋﻮﻟﻬﻢ ﺻﺤ‬
‫ اﻟ‬.� ‫ﻋﻠ �� واﻋﺘﻘﺎدي وﻟﻢ أﺣﺠﺐ أي ﻣﻌﻠﻮﻣﺎت ﺟﻮﻫ��ﺔ وﺳﺄﺧ‬
information stated in your quotation is incorrect. It is �
understood and agreed that this declaration which is contained ‫ﺔ ﻟﻠﺘﺄﻣﻴﻨﺎت اﻟﻌﺎﻣﺔ ﻋ� اﻟﻔﻮر إذا �ﺎﻧﺖ أي ﻣﻦ‬i‫� ﻛﺔ اﻟﻮﻃﻨ‬
�
in the application form constitutes the basis of my/our ‫ ﻣﻦ‬.‫ﺤﺔ‬i‫� � ﻋﺮض اﻷﺳﻌﺎر ﻏ � � ﺻﺤ‬ ‫اﻟﻤﻌﻠﻮﻣﺎت اﻟﻮاردة‬
contractual relationship with National General Insurance Co �
‫� � اﺳﺘﻤﺎرة‬ ‫ﻪ أن ﻫﺬا اﻹﻗﺮار اﻟﻮارد‬i‫اﻟﻤﻔﻬﻮم واﻟﻤﺘﻔﻖ ﻋﻠ‬
(PJSC) and that any non-disclosure or misrepresentation of
‫ ���ﻋﻼﻗﺘﻨﺎ اﻟﺘﻌﺎﻗﺪ�ﺔ ﻣﻊ اﻟ � ﻛﺔ‬: ‫اﻟﻄﻠﺐ �ﺸ�ﻞ أﺳﺎس ﻋﻼﻗ‬
�
facts will make my / our insurance coverage void from
‫ﺔ ﻟﻠﺘﺄﻣﻴﻨﺎت اﻟﻌﺎﻣﺔ‬i‫اﻟﻮﻃﻨ‬
inception. I hereby authorize any hospital, physician, surgeon or ‫ع( وأن أي ﻋﺪم إﻓﺼﺎح أو ﺗﺤ��ﻒ ﻟﻠﺤﻘﺎﺋﻖ ﻣﻦ ﺷﺄﻧﻪ‬.‫م‬.‫)ش‬
any other organization to furnish to the National General ‫ أﻓﻮض �ﻤﻮﺟ�ﻪ‬.‫ﺔ ﺗﺄﻣﻴ � ���ﺗﺄﻣﻴ�ﻨﺎ ﻣﻦ اﻟ�ﺪا�ﺔ‬i‫أن ﻳ�ﻄﻞ ﺗﻐﻄ‬
Insurance Co (PJSC)/ (or NEXtCARE® on behalf on National : �
General Insurance Co (PJSC) any or all information that may be ‫ﺐ أو ﺟﺮاح أو أي ﻣﺆﺳﺴﺔ أﺧﺮى ﺑ ��و�ﺪ اﻟ‬i‫أي ﻣﺴ�ﺸ � أو ﻃﺒ‬
required concerning my/ our medical history. ‫ﻜﺴﺖ‬i‫ع( � أو ﻧ‬.‫م‬.‫ﺔ ﻟﻠﺘﺄﻣﻴﻨﺎت اﻟﻌﺎﻣﺔ )ش‬i‫��ﻛﺔ اﻟﻮﻃﻨ‬
I understand and acknowledge any pregnancy not declared at (‫ع‬.‫م‬.‫ﺔ ﻟﻠﺘﺄﻣﻴﻨﺎت اﻟﻌﺎﻣﺔ )ش‬i‫ﺎ�ﺔ ﻋﻦ اﻟ ��ﻛﺔ اﻟﻮﻃﻨ‬i‫ﻛ � � ﻧ‬
the time of this application’s coverage will be at the sole �
�‫ � � ﻗﺪ ﺗﻜﻮن ﻣﻄﻠ��ﺔ �ﺨﺼﻮص ﺗﺎر‬: ‫�ﺄي أو ﺟﻤﻴﻊ اﻟﻤﻌﻠﻮﻣﺎت اﻟ‬
discretion of the insurer. The insurer has the right to not cover
any maternity claims to any undeclared pregnancy. I also � � . .‫� �� ﺗﺎر�ﺨﻨﺎ اﻟﻄ‬
acknowledge and understand any pregnancy, which arises ‫أﻓﻬﻢ وأﻗﺮ أن أي ﺣﻤﻞ ﻟﻢ ﻳﺘﻢ اﻹﻋﻼن ﻋﻨﻪ وﻗﺖ ﺗﻘﺪ�ﻢ ﻫﺬا‬
‫اﻟﻄﻠﺐ ﺳﻮف ﺗﺨﻀﻊ‬
within forty calendar days from the date of this application;
�� � ‫ و�ﺤﻖ ﻟ ��ﻛﺔ اﻟﺘﺄﻣ‬.‫�ﻛﺔ اﻟﺘﺄﻣ � �� ﻣﻨﻔﺮدة‬s ‫ﺗﻐﻄﻴﺘﻪ ﻟﺘﻘﺪﻳﺮ‬
coverage will also be at the discretion of the insurer.
.‫ﺔ أي ﻣﻄﺎﻟ�ﺎت ﻣﺘﻌﻠﻘﺔ �ﺤﻤﻞ ﻟﻢ ﻳﺘﻢ اﻹﻋﻼن ﻋﻨﻪ‬i‫ﻋﺪم ﺗﻐﻄ‬
‫�ﻤﺎ أﻗﺮ وأﻓﻬﻢ أن أي ﺣﻤﻞ �ﺤﺪث‬
�
‫ﺧﻼل أر�ﻌ � �� ﻳﻮ ﻣﺎ ﻣﻦ ﺗﺎر�ــــﺦ ﻫﺬا اﻟﻄﻠﺐ؛ ﺳﻮف ﺗﺨﻀﻊ ﺗﻐﻄﻴﺘﻪ‬
�
‫أ� ﻀﺎ ﻟﺘﻘﺪﻳﺮ‬
.‫�ﻛﺔ اﻟﺘﺄﻣ � �� ﻣﻨﻔﺮدة‬s

I understand that “Pre-existing Condition means any Disease, �

Illness or injury for which a person receives Treatment or ‫أﻋﻠﻢ أن "اﻟﺤﺎﻟﺔ اﻟﻤﻮﺟﻮدة ﻣﺴ� ﻘﺎ ﺗﻌ � � � أي أﻣﺮاض أو‬
� � :
experience symptoms, incurs expense, receives diagnosis from ‫ أو‬،‫إﺻﺎ�ﺎت ﻳﺘﻠ � اﻟﺸﺨﺺ ﻋﻼ ﺟﺎ ﻟﻬﺎ أو �ﻌﺎ � � ﻣﻦ أﻋﺮاﺿﻬﺎ‬
a physician (even if no Treatment is provided) or was aware of :
‫ إذا ﻟﻢ ﻳﺘﻢ ﺗﻘﺪ�ﻢ‬:� ‫ﺐ )ﺣ‬i‫ﺺ ﻣﻦ ﻃﺒ‬i‫ أو ﻳﺘﻠ � اﻟ�ﺸﺨ‬،‫ﻳﺘﺤﻤﻞ ﻧﻔﻘﺎﺗﻬﺎ‬
at any time prior to applying for insurance” and acknowledge �
‫ﻋﻼج( أو �ﺎن ﻋ� ﻋﻠﻢ ﺑﻬﺎ � � أي وﻗﺖ ﻗ�ﻞ اﻟﺘﻘﺪم �ﻄﻠﺐ‬
that any non-disclosure, misrepresentation shall result in
non-coverage of the condition and/or invalidate the policy. ‫ﻟﻠﺤﺼﻮل ﻋ� ﺗﺄﻣ � " �� وأﻗﺮ �ﺄن أي ﻋﺪم إﻓﺼﺎح أو ﺗﺤ��ﻒ‬
‫ﺔ‬i‫ﺳﻴﺆدي إ� ﻋﺪم ﺗﻐﻄ‬
.‫ﻘﺔ‬i‫اﻟﺤﺎﻟﺔ و�أو إﻟﻐﺎء اﻟﻮﺛ‬
“As per article (38) of Cabinet Decision No. (10) of 2019 AML and (‫ع‬.‫م‬.‫ﺔ ﻟﻠﺘﺄﻣﻴﻨﺎت اﻟﻌﺎﻣﺔ )ش‬i‫" ﻳﺘﻌ � �� ﻋ� اﻟ ��ﻛﺔ اﻟﻮﻃﻨ‬
CFT regulations, National General Insurance Company (PJSC) ‫ﻣﺸﺎرﻛﺔ اﻟﻤﻌﻠﻮﻣﺎت‬
�
would be required to share customer related information with
�
relevant authorities at the domestic and international levels. You �� ‫ﻞ ﻣﻊ اﻟﺴﻠﻄﺎت ذات اﻟﺼﻠﺔ ﻋ� اﻟﻤﺴﺘ�� � � اﻟﻤﺤ‬i‫اﻟﻤﺘﻌﻠﻘﺔ �ﺎﻟﻌﻤ‬
acceptance of this proposal includes your consent in permi�ng ‫ � � وﻓﻘﺎ‬. ‫واﻟﺪو‬
National General Insurance Company (PJSC) to share such ‫ ﻣﻦ‬2019 ‫) ﻟﺴﻨﺔ‬10( ‫) ﻣﻦ ﻗﺮار ﻣﺠﻠﺲ اﻟﻮزراء رﻗﻢ‬38( ‫ﻟﻠﻤﺎدة‬
information. ‫ ﻳﺘﻀﻤﻦ‬ṿ.‫ﻟﻮاﺋﺢ ﻣ�ﺎﻓﺤﺔ ﻏﺴﻞ اﻷﻣﻮال وﺗﻤ��ﻞ اﻹرﻫﺎ‬
‫ﻗﺒﻮل ﻫﺬا اﻟﻌﺮض ﻣﻮاﻓﻘﺘﻚ ﻋ� اﻟﺴﻤﺎح‬
‫ع( �ﻤﺸﺎرﻛﺔ ﻫﺬە‬.‫م‬.‫ﺔ ﻟﻠﺘﺄﻣﻴﻨﺎت اﻟﻌﺎﻣﺔ )ش‬i‫ﻟﻠ ��ﻛﺔ اﻟﻮﻃﻨ‬
.‫اﻟﻤﻌﻠﻮﻣﺎت‬

/ / :‫ــــﺦ‬i‫اﻟﺘﺎر‬ :Date / / :‫ــــﺦ‬i‫اﻟﺘﺎر‬

:Date
 MEDICAL
Applicant’s Signature Sponsor’s Signature
‫ﺗﻮﻗﻴﻊ ﻣﻘﺪم‬ ‫ﻞ‬i‫ﺗﻮﻗﻴﻊ اﻟ�ﻔ‬
‫اﻟﻄﻠﺐ‬
(On behalf of Self & Family Members/ ‫اﻟﻌﺎﺋﻠﺔ أﻓﺮاد ﻋﻦ ﺔ�ﺎ‬i ‫ﺎﻟﻨ�و‬ (If the premium is paid by the Sponsor/ �. � ‫اﻟﺘﺄﻣ ﻟﻘﺴﻂ ﻞ‬i ‫ﻔ�اﻟ دﻓﻊ‬
‫)�ﺸﺨﺼﻪ‬ .
‫) �� ﺣﺎل‬

Form
Health Declaration