D E C L A R AT I O N F O R M

Product Type:

Institutions and companies

Saudi families

Individual resident

Request Type:

Issue new contract

Renew previous contract

Amend/addition of current contract number:

Domestic help

Existing or previous contract ID# or membership #

Part 1: Applicant Information
Company/Institute/Family Name:

Commercial Registration:

Name as it will appear on the card:

Name of the authorized person*:

Gender:

Male

Nationality:

ID No.:

Date of expiry:

Employer name:

Job title:

City:

Address:

P.O. Box:

Mobile:

Postal code:

E-mail address:
Telephone:

Fax:

Preferred bank:

IBAN No:

Female

S A

*This declaration form is to be filled by the insured person, the head of the family, legal representative or authorized official of the institution or company.

Part 2: Medical Declaration

Please declare the presence of any of the following conditions with reference
in front of them. Do you have:
1.
2.
3.
4.
5.
6.
7.
8.

9.
10.
11.

12.
13.
14.
15.
16.
17.
18.
19.

20.
21.
22.
23.

Part 3: List of the Patients Names

Yes

Future plans for (Artificial / Natural) organ transplants.

Admission case currently in the hospital or any hospital admission
within the last 14 days or receiving treatment in emergency.
Central nervous system diseases limited to: Stroke, Epilepsy.
Tumor or Cancer.
Heart conditions limited to: Arrhythmia, Ischaemic heart disease (IHD),
Open heart surgery (CABG), Catheterization, Pacemaker, Valve disease.
Liver disorder limited to: Hepatitis, Cirrhosis, Esophageal varices,
Gallbladder stones.
Urinary tract disorder limited to: Renal failure, Urinary tract stones.
Autoimmune disorder limited to: Ankylosing spondylitis, Multiple
sclerosis (MS), Psoriasis, Systemic lupus erythematosus (SLE),
Rheumatoid, Ulcerative colitis (Crohn's).
Vascular disease limited to: Phlebitis, Varicocele, Varicose vein,
Vasculitis, Aneurysm.
Blood disorder limited to: Sickle cell anemia (SCD), Hemophilia,
Thalassemia, Leukemia.
Congenital disorder & Hereditary disease (Diseases resulting from
defects or genetic disorder and transmitted from one generation to
another, or that affect the individual during fetal life)
Uncontrolled Diabetes / Hypertension cases needing admission from
time to time.
Eye disease limited to: Cataract, Glaucoma, Corneal & Retinal condition
Ear disease limited to: Hearing loss, Equilibrium problems, and Cochlear
problems.
Bone disease limited to: Disc prolapse, Arthritis, Scoliosis, Ligament
tears, Osteoporosis.
Tissue disease limited to: Abnormal tissue growth, Cyst, Hernia, Ulcers
(Bed sores, Diabetic foot).
Current pregnancy for female employee or employee's wives
Current multiple pregnancy or baby with congenital anomaly
History of abortion or previous Cesarean section delivery or
instrumental assisted or premature labor or baby with congenital
anomaly.
Is the current pregnancy outcome of any assisted way of conception
includes but not limited to (IVF, Hormonal induction, etc)?
Alzheimer
Autism
Handicapping

Please provide us with names of members with cases from part 2 and
determine the type of condition while attaching recent medical reports
(not exceeding 3 months) for each condition.

Condition

Name

Part 4: Confirmation and Authorisation

1.

2.

3.

I / We confirm that all mentioned data in this form is complete

and correct and has been discussed with all staff and their
families in a manner not inconsistent with the privacy and
confidentiality of the information, and the acceptance of the
application will be based on this data. Bupa Arabia for
Cooperative Insurance has the right to contact the hospitals
which I am / We are dealing with to provide any medical
information that may be needed to assess the risk.
I / We agree that Bupa Arabia for Cooperative Insurance have the
eligibility to reject the claim or the entire coverage at concealment of any unexpected case or any case that arose before the
date of the contract, enrolment, or addition, even if the cases
mentioned in the medical disclosure whether the cases are
undiagnosed before unless if there were accepted by Bupa Arabia
in writing.
I / We undertake to perform similar declaration in the future on
members who will be added during the contract period or upon
renewal as all old and new Declaration forms are considered as
integral part of the current and future contracts.

I certify that I have read and understood all stated points in this form. I also undertake that if I didnt tick any of the above situations then it is considered
as a denial to the existence of that declared case; and on that I sign.
Date:

Signature:

Please keep a copy of all the supplied documentation, medical records and correspondence between Bupa Arabia and yourself.
You may contact us at Toll-Free: 800 116 0500 or E-mail: business@bupa.com.sa

Stamp: