Oman Insurance Company

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PROPOSAL FORM INDIVIDUAL MEDICAL INSURANCE

Please complete this form using BLOCK CAPITALS and by ticking the relevant items. Kindly enclose Passport copies and photographs of the members to be insured.

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Name
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Applicant's Details

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Occupation :.

Gender ~I Marital Status

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Male
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Date of Birth
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Dependents' Details.

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No. of,Children
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Weight (kg)

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UAE Residents Only

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. Relationship to Applicant
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Date of Birth Weight (kg) I uj)1 Day fY. Month~

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Address

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co~~~ame:

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~~Ie~~~~I----------------------------- ReJiwi1--??-':r.rr-1J-~1_-<f-----I 4. (a) Geographical Coverage Required

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UAB only
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r-J UAB, occ & Indian

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Sub-Continent

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UAB,GCC &. Indian Sub-Count plus emergencytreatment worldwide Iex. USA & Canada) I,;S J lS;.J"II.>r. L. ,JWI Jy Js .) l,.; .)UJI wYWI+ WJWlI<.J>4.. Jy ,wly... ')II

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GCe: & Indian Sub-Continent plus emergency treatment worldwide '(including. USA & Canada) I,;S J lS;.J"1t:',JW1 Jy Js.) l,.; .JUJIwyWI+ WJWlI <.J>4.. Jy ,wl.JL.')I1

(b) Network
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OIC Restricted Network '.J~I

OIC Comprehensive Network ~I..':JI~I

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5.Medical History

a) Have you or any person you wish to insure sought medical advice, received medical treatment or suffered from any medical condition (whether medical treatment or medical advice was given or not) other than for minor illness, during the last 24 months? 1'>....".':1124 JI ~':II J)l;. (~.,J fi ~ ~.I"...) ~;iJt". ~i 0- r.s'~"i ~4Jt.... ~1r;:;.".,.;1II;" ~ . IC).l.o _A~ ",I",i UJi ~ J,. (I Dyes ..

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b) Have you or any person you wish to insure consulted with a specialist, been admitted to a hospital, nursing home or any other medical :!J;..J <,$1 Jl ~~I

facility or been advised to have any medical examinations or investigations during the last five years? ~ Ji ~I ~l Jy..>lIU"'~ ~t......;.iJl.)~ LY' ~ ,.)w:;..1 ~1r;:;.".,.;1II;" ~ . I ~y..,fti ~ ",i) w;l wfoiJA(,:, d . 1'>.Ji>.':I1 ~1';'1y..l1 J::L;..~ w1......"""; J-; 6."......,....::.:.s .J1lS,ftl ~

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Continued

011 II

ext page

Mahmoud S. Shalab Medical Underwriting

Oman Insurance Company

(P.S.C.)

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6.Life Style a) Do you or any person(s) you wish to insure is a professional

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sportsman or engage in any hazardous sports or activities? <!l..JW: .,1 W~ ~4.J <!lillie. 0-.~ <?I.,1..:.;1j&

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DYes""'; lfyou have answered

YES, please give details of your activities:

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b) Do you or any person(s) you wish to insure: Smoke~ Drink Alcohol J~I yfo Stay abroad for more than 60 days during the year L.J! 60 0" fol ~ .,.>11 <:;:..Jli. ~ If you have answered YES, please give details of quantity and frequency:

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Yes Yes Yes

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No No

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7.1.lIsura:nce History

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a) Are you presently insured under any other health insurance coverage? !..foi ~ u,;.-I:i ~I <:;:o..,...;Jll:"" ~ .:.t....i u:ufi;..!1 LJ.o~ ,,1.,1 d ~

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b) Are you currently making or do you intend to make any life, accident, critical illness or health Insurance proposals to any other msurance company? !.s..fol u,;.-l:i'..Sy:o "I c!""~u,;.-l:i) &OJ-...,.,yJ .,1w.:.1.".l1"..,.,1 '~I ~ u,;.-l:i~1 4.ll ufo.i) ~WI ~)I ~ ".iiO.,1 4b4i.ll c)H!l$ any of your application for life, accident, critical illness or health insurance been declined, Postponed or accepted on special terms? !~\.ti:i...I.l..,.h J;!.,I J;! jo"""'..J ~ u,;.-i:;J1",I ~I.".ll '~I ~ u,;.-i:;JJ yll. <il 4i.ll ~J! Jo.

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Yes

NO

Yes

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Yes

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NO

d) Has a company terminated or refused to renew your contract of life, accident, eritieal illness or health insurance? f~ u,;.-l:i.}0-.>o...,.,yJ) w.:.1.".l1"..,.,1 '~I ~ <!ll u,;.-I:i ~I =.11.,1 ~I:i ~ ui ~..J'..S~ ~I

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Yes

If you have answered

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YES to any ofthe

above questions,

please give the following

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information:

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Year

Name of the Company

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Sum Insured

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- I hereby declare that to the best of my knowledge and belief the above particulars are true and complete and full information has been disclosed. I understand that non-disclosure or misrepresentation of any fact may lead to the refusal of an.yclaimor the cancellation of any policy. ;w.li.~I..).... ~I ~\kl;iJh ~ <j4 c}=!.)i.L.S L.).... ~ .1ii..! H,J., uas , ~ ~.)lc.1 4-! Wo..Y-" ~I~L.~I J!; u4".lLO:ici.,.}= LJ=>.4 <jl UA c.Y-"'}"'4 ~I .Wj ~ .,.);i u- .. ,,;,. ~ ,-:!I"""'..J ull ,,"':';" I:"" uli <'y\i", ~I .1ii..! - I hereby authorize the giving of (a) medical information from my doctor and any doctor who has at any time attended me and (b) information from any life / health assurance office to which a proposal on my life has at any time been made. ...r.:i...oWI ~I ~L.)...JI~\kH.~1 ~ u,;.-b.,1~u,;.-l:i'..S~"I.,1 ,~~."i;y..i y,;.;1...,1 .,!U"'WI ~UA ...,.,.,;1~l L.S_ - I hereby agree that this proposal and declaration or any written statement made by me in reference to the proposal shall be the basis of the contract between the Company and me. .~ U:!!~ ~"'\ .,.. ufo:.. yl.bJ\ t.,...;..JA!.. ~ .u ~ 0- J~ u4 L..c.;1 c:;>1-" ."..;.;1 L.S_

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Applicant's

Signature:

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Date.

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Mahmood s. Shalab Medical Underwriting

Oman Insurance Company

(P.S.C.)

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Have you or any person(s) you wish to insure ever suffered from any following. Please answer "Yes" or "NO" to all questions written below:
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2.
3. 4. 5. 6. 7. Heart ,Blood vessel, Hypertension and circulatory diseases Congenital and hereditary diseases Cancer, and blood d.iseases Neurological, mental and psychological disease Kidney and calculus disease Digestive disorders Respiratory system diseases Skin and subcutaneous tissue diseases AIDS Boneand.muscle diseases Genitourinary system disorders I.. vmphatic system diseases Your wife pregnant Endocrine and metabolic disorders like diabetes

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15. Rheumatoid and irurnunology 16. Pre-operative and operation I?Ba.ckPain 18. Nervous system diseases 19, Eye and Ear diseases 20_ Any sickness, medical complication., any condition not listed above Cl

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If answer is "Yes" to any of the above question, please give the full details below . .~YI ~I.) ~I..i:ill pol ~t.JI Uw,Y\<s""'l.)c (~) Pre-existing No. Insured Name
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Medical

Conditions

& Previous

Operation Date of diagnosis/treatment/operation

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3. Diseases Details .t>'> yJl J:....,li

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5. Current No. rAjl L 2. 3. 4. 5. Insured Name
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Medications Daily Dosage A.;..~\:i.:.~1 Date from which medicines were started
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d) Has any member of your family (patents, brothersor

deformity,
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sisters) had heart disease, high blood pressure, cancer, nervous or mental disorders, kidney disease, hemophilia and/or muscular dystrophy?

diabetes,
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congenital

disease or
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~NO'1 YES, please give the following

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information:
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Continued

on next page

Malnnoud S. Shalab Medical Underwriting