Health Declaration Form

Important Note: Kindly disclose complete medical history in this form. Please note that if the pre-existing medical condition is NOT DISCLOSED, we may decline
the claim relating to it. If the medical condition is disclosed, we may / may not cover that medical condition subject to the terms and conditions of this
policy.
Pre-existing medical conditions are diseases, Illness or injuries of a person against which he/she receives treatment, incurs expenses, receives diagnosis from a
doctor (even if no treatment is provided) or was of at anytime prior to applying for insurance.
Client's Name:
Employee/ Dependent's Name:
Designation/ Employment Joining Date:
Employee Code/ Marital Status/ Blood Group:
C.N.I.C #/ Mobile #:
Residential Address:

Family Details: Please write Family members (spouse, son, daughter) to be covered. Attach additional form, if necessary
Name in CAPITAL letters

S. No.

Relationship

Sex (M/F) Birth date

Height & Weight

Marital status

Marriage date

Insurance
Effective Date

Self

2
3
4
5
6

Compulsory information to be provided:

Yes

Are/have you or any member of your family listed above (spouse/children) currently or at any time prior to applying for insurance
1

Consulted a medical practitioner or specialist within the last 12 months.

Suffered from or aware of any medical condition/disease/illness or injury (even if no doctor was consulted).

Told by the doctor that surgery or special medical tests or treatment might be required or necessary at some future date.

Suffered from high blood pressure, Heart Disease, Diabetes, Paralysis, any disease of Brain or Nervous System, Renal Disease, Cancer
or Tumor, Arthritis, Rheumatism, Disease/Disorder of the liver, AIDS or any other disease or illness not mentioned above.

Regularly took medication for more than a week time (prescription or other).

Suffered from any mental or physical disabilities or defects.

Do you or your covered dependent have any other medical insurance from another insurance company

Do you or any of your family member smoke.

Is your spouse (or yourself, if you are a female, pregnant? If yes. Please state which month(s) of pregnancy ______________________.

Name of member ____________________________

Name of Doctor & Hospital: _________________________________________

10

No

Last delivery mode:

From ___________________
Normal

C-Section

Are you or any of your dependent(s) is / are insured with any other insurance company

If you have answered Yes to any of the questions 1-9 above, please provide details i.e. name of the person, nature/ duration of illness, name of
attending physician/ hospital, type of treatment and whether any further tests/treatment/ suggested/required. Attach additional sheets if necessary
and also attach photocopies of the relevant medical reports & or prescription of medicine.

Declaration: I hereby certify that I have filled the above information to the best of my knowledge and belief.
Plan

With this form please attach (Where applicable)

1)
2)
3)
4)

CNIC Copy of all adult eligible family members insured under this policy.
Copy of Marriage deed.
NADRA's birth certificate for kids under 18.
For Dependent's addition, copy of employee's insurance card

________________________________
Signature of Employee
for self and on behalf of his/her dependent Dated

________________________________
Name, Designation & Signature of Client's authorized officer
with official seal Dated

Head Office: Lakson Square, Building No. 3, 11th Floor, Sarwar Shaheed Road, Karachi-74200, Pakistan. Phones: 92-2135657445-9 Fax: 92-21-35671665