This document provides guidelines for filling out a membership maintenance form. It notes that all fields on the form are mandatory and must be filled out clearly. It explains the different transaction types that can be selected and which fields must be filled out for each type. Additional documentation may be required depending on the transaction. The guidelines also provide information on adding more than 4 dependents and instructions for filling out a second form. General rules outlined on page 3 include eligibility requirements, coverage start dates, and Bupa's right to request additional documentation to decide on enrollment.
This document provides guidelines for filling out a membership maintenance form. It notes that all fields on the form are mandatory and must be filled out clearly. It explains the different transaction types that can be selected and which fields must be filled out for each type. Additional documentation may be required depending on the transaction. The guidelines also provide information on adding more than 4 dependents and instructions for filling out a second form. General rules outlined on page 3 include eligibility requirements, coverage start dates, and Bupa's right to request additional documentation to decide on enrollment.
This document provides guidelines for filling out a membership maintenance form. It notes that all fields on the form are mandatory and must be filled out clearly. It explains the different transaction types that can be selected and which fields must be filled out for each type. Additional documentation may be required depending on the transaction. The guidelines also provide information on adding more than 4 dependents and instructions for filling out a second form. General rules outlined on page 3 include eligibility requirements, coverage start dates, and Bupa's right to request additional documentation to decide on enrollment.
Membershi p Mai nt enanc e For m ,.n| _ni u'.| .,,
Al l t he bel ow f i el ds ar e mandat or y, pl ease f i l l i n c l ear f ont ,';;| o'i.| _,ui| ,; . .,uc .| L ,|i.| .';,| . Transacti on effective date ,n| uii ,,L,..| ,'i|
Pl ease f ax t hi s page t o u, _:'u oc iu.| oc _'.,| .';,; 920 000 725 Contract Number un| u,
Company Name :,u| .|
TRANSACTI ON TYPE / ,n| ,i Pl ease c hoose (f i l l i n) one of t he bel ow t r ansac t i ons: All the below options require additional documentation (refer to general rules in page 3). For any assistance on how to fill out the form, please read the guidelines in the following pages. : ,'i| .';,| ) _Li ( ;,L,.| ,n| _'i,| _n; _'u,| ,Lii o'i.| .',n| ,; ) u| o.|,u .';,| iu. g c'n| c|, 3 o;, o'i.| ,'u,\| 'nc .,,i| ;ni u,L u,n,. 'i| .'iu.| g i.,,.| .|.'.,\| o.|,u Add new employee and dependent(s) i'c ; cL,c u'.|
Add new born u'.| ; .,,c
Add dependent(s) of an insured employee _c,c cL,c 'cu'.|
Replace card(s)(lost/ Data correction) Employee Dependents u'L;| _|;i.| ) u'u _; - .'c,nc i.i ( cL,, 'n
Re-activating ui ,.c _nui o.'c|
Delete an employee ( Dependents will be deleted automatically) cL,,.| .'n| ) _'n,.| ,; .'n| i. (
EMPLOYMENT DETAI LS / cL,,.| .'i'; Current membership no (skip if new member) 'i| ,.n| u, ) ; cL,c u'.| ': g ,,Lc c (
Gender _i;| F oii|
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Employee No. cL,,. | u,
Name as per the ID ( First Middl e Last ) ,c| | c'u)| ,u: .\| ( ) _\| - L.\| - ,u|
Date of Birth (Gregorian) .\,.| ,'i ) .\,.'; (
DD/MM/YYYY Requested Level of Cover ;,L,.| Lni| ;,.
Iqama or Saudi ID ,c| | c'u\| u, iL,|
Sponsor ID _u.| u,
National ity ui;|
Branch name ,u| .|
Reason ,;u|
DEPENDENTS DETAI LS / 'n.| .'i'; Current membership no (skip if new member) 'i| ,.n| u, ) _': g ,,Lc c o;u'.| ( Name as per the ID ( First Middle Last ) ,c| | c'u)| ,u: .\| ( _\| - L.\| - ,u| )
Iqama or Saudi ID | c'u\| u, iL,| ,c|
Date of Birth .\,. | ,'i DD / MM / YYYY
Nationality ui;.|
Relationship ;|,u| .
Gender _i;|
Please mark this box if you have more than 4 dependents to add and follow step 3 in the guidelines (page2) _c ,:| u'.| ..,| _': g ;,,.| |c _Li o;, 4 .',ni| ;i| i . _'nc g i.,,.| o,uu| 3 .,,i| ;ni .|.'.,| _c u. g i 2
I certify that the information given on this form and in any documents attached is correct, complete and accurate. I understand that the information provided by me maybe verified and hereby consent to such verification activities. I also understand that providing false or misleading information may result in canceling the membership and may be grounds for any legal accountability. ,|,u| : | ,; i.; ,u| ,. gii| . ; uu,c o,| ui | .,,i| |c g o.,|,| .'c,n | _| cui| ,. .' _,.i u .'c,n n .|.|,;\| oc _ic _;ui| gii| . _ui | pui _| c,. '.'.| _i u ,.n| .'n| C| ., u,. .c | L' .'c,nc | , .'u i,i'u| . Company Stamp / u.,,.| | :,u| i:
Authori zed name and si gnature / : nu,i _,,.| .|
Page 2 of 5
Guidelines:
Thi s secti on provi des some gui del i nes on how to fil l in page 1. Depends on transacti on type, you get to fil l i n the necessary i nformati on that sati sfy our requi rements. You can always call our membership team on 800 4400 555 for any clarifications during the working hours (9 am- 5 pm) Sat to Wed.:
1. Transaction date, contract number and company name are mandatory fields and must always be provided, regardless of the transaction type. 2. Pease refer to the below schedule and make sure you fill all the fields corresponding to their numbers stated below: Transacti on type Mandatory fi eld number Notes Add new Employee and Dependents Employee only: From 2 t o 10 Employee and dependent: From 2 t o 10 And From 13 to 18 3 only if applicable Add new born 1 - 4 - 7 - 8 From 13 to 18
Add dependents of an insured employee 1 - 4 - 7 - 8 From 13 to 18
Replace cards 1 - 4 - 11 The fields from (2 to 10 for employees or from 12 to 16 for dependents) will be filled according to the reason.
Example: if the reason is wrong Employee name, field number 2 must be filled Re-activating For Employee: 1 - 4 - 11 For Dependents: 1 - 4 - 11 - 12 - 13
Delete an employee and Dependents 1 - 4 - 11 Delete Dependents 11 - 12 - 13 - 14 Employee upgrade or downgrade 1 - 4 - 6 - 11 Transfer to a new branch 1 - 4 - 10 In field no. 10, only the new branch name must be provided.
3. If you wish to add more than 4 dependents, please fill-in the second form dependents addition and make sure you do the following: Fill-in all the fields because all are mandatory. Sign it and stamp it. Fax this request together with the original one.
The bel ow rules were desi gned i n compli ance with the Council of Cooperati ve health Insurance (CCHI) and Saudi Arabi an Monetary Agency (SAMA):
General rul es:
Bupa covers Saudi nationals and members who are having valid Iqama or valid resident visa. Agreement does not include any relatives except wives and unmarried children. This application form is considered part of the signed agreement and subject to the agreements terms and conditions. Substituting a member by another is not possible. Customer shall immediately notify the company in writing of all employees or dependents to be covered by insurance after the effective date of the policy, and company shall immediately calculate additional contribution payable for persons incorporate in the insured persons schedule on a proportional basis starting from date of their coverage. The coverage of the employee who is actually on the job shall commence as from date of commencement stated in the policy - schedule, - and any person who joins work at a later date shall be covered as from date of joining work with customer or date of arrival in the Kingdom. The effective date of insurance coverage for dependents shall be the date of insuring the employee - who supports them - or the first date on which they enjoy the status of dependents. If customer submit request to enroll a member or dependent under the healthcare program, Bupa Arabia reserves the right to access the personal files and request any documentation may find it necessary to decide on the enrolment of any employee or dependent. This process will be discretionary and can be done randomly or on every case at the point of enrolment or at a later stage whenever Bupa Arabia identifies a need to do so. If at any stage Bupa Arabia concludes that there is an intension for abuse or enrolment circumstances indicates discrepancy in data provided, Bupa Arabia have the right to fully or partially reject to cover any service cost and can terminate membership immediately without any advance notice. Backdating enrollment and deletions must not exceed 30 days period.
Terms and Condi ti ons: A. Condi ti ons of enrollment: The member should be an employee within the organization. Attach a copy of the National ID card for Saudis or Iqama, GCC citizens passport, or diplomatic card for diplomats must be submitted for non Saudis when submitting the request Per CCHI regulations, customer should enroll any employee within 10 days of their company joining date. _.;.,. n,.| uii| i\| c _u|,ii .n. o'i.| c|,u| ui| u.,c gi.| _',.| .,nu| g;,n| :
Attach a copy of the passport if the applicant has newly arrived to KSA. Attach a copy of the birth certificate or hospital birth report when enrolling new born babies. All new born must be added from their date of birth, according to the signed agreement. Attach a copy of mirage certificate when enrolling spouses. Adding an employee on a different sponsor will require attaching the following documentation: Copy of Employees contract Copy of the employment lease (labor lease contract) signed and stamped by the Chamber of Commerce. Copy of the letter of the responsibility pledge, signed and stamped (please check with the Relationship manager for details) Attach a copy of the medical deceleration form, once it is clearly stated in the signed agreement. Valid Iqama numbers must be provided for dependents, which differ from the main members Iqama number (Employee in this case).
B. Condi ti ons of card repl acement (data correcti on- l ost): For date of birth and name amendments, a copy of the members National ID card for Saudis or Iqama, GCC citizens passport, or diplomatic card for diplomats must be submitted for non Saudis. For Saudi ID, Iqama or sponsor ID number amendments, a copy of the members National ID card for Saudis or Iqama, GCC citizens passport, or diplomatic card for diplomats must be submitted for non Saudis.
C. Condi ti ons of re-i nstati ng: A letter justifying the reason for reinstating the member. A confirmation that the member doesnt suffer from any major health condition.
D. Condi ti ons of del eti on: Copy of the resignation letter must be submitted for Saudis.
In case of expatri ate members, they wi ll be onl y del eted accordi ng to the bel ow: Final exit (a copy exit visa must be submitted). No return (a copy of Attestation of no return must be submitted Mashhad Adam Awdah). Sponsorship transfers Kafala Transfer (the client needs to submit the sponsorship transfer documents along with a confirmation letter of membership from a CCHI approved company) before terminating the member. Death (copy of death certificate or death report must be submitted). Deletion process will only take place, upon the date of receiving of the insurance cards/ membership cards of the terminated employees. 'uu gi.| _',.| _.; _i|,u L,,.| u'.| ,; _\ c 10 ,'| _,n'; _'ii\| ,'i _c . _,i cL,,.| _': _': g ,uu| ,|,; _c o,,. _'u,| o.'i _,. . | o.'c. _c o,,. _'u,| ,. .\ o.\,| ;i | | u'.| ic ,. .;| |, . ,; .\,.| ,'i _c .;| |,,.| u'.| , u,,.| un 'n;i . _c o,,. _'u,| .';,| u'.| ic |,| uc . u.,,.| | :,u| 'u: c oc cL,c u'.| _': g , _'u,| .';,| : _,n| uc _c o,,. . ,';i| u,n| _c _.c ',n| ,';i.| uc _c o,,. . _c'n| _c ,u,.'; cni| ,'L _c o,,. _'u,| ) o;, g un| _c _,u,.| _u| n;|,c ';,; ( c. oc _ii gi| .,un '.u\| .,, _'u,| ,; ) L:\c : _: i,.| c :| cL,c _ g;L '.u| .,, ( ,; cL,,.| _c cii gi| _'n,.'; .'| .'c'u)| ,'u,| ,i ) _n,.| (
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Page 5 of 5
Reference to the decision of the Council of Cooperative Health Insurance session No. 72 dated on 4-3-1430H 1-3-2009 on how to handle workers whom ran away from their sponsors; it has been decided that health insurance company are not allowed to terminated the policies of these workers and they should remain active till it expires.
E. Condi ti ons of upgrade or downgrade: When requesting a scheme upgrade, a copy of the promotion letter must be attached ( signed and stamped ) When requesting a scheme downgrade, a copy of a letter justifying the downgrade must be attached. ( signed and stamped )