Employee Health Insurance Form for 2020

Employee Information:
Employee Number: S-IR-4011
Position: Community Mobilizer
Date of Birth: July 20,1995
Start Date: July 19th
Email: Kovan.aram@gmail.com
Employee Name: Kovan Rafiq Abdullah
Work Station/Office: Erbil Office
Gender: Male
Nationality: Iraqi
Phone number: 07701241083

First Option: Features of Asia Health Insurance Company for SWEDO Employees:

Account Manager for SWEDO Yes

Waiver of waiting period Waiver of waiting period to the existing
employee list. Waiting period shall be
applied to all members insured after
inception date. As for New enrollees,
standard terms and conditions shall be
applied.
Payment out of Iraq All over Iraq and Jordan is covered on
reimbursement basis according to the
customary rates of med net Kurdistan
Emergency (only Iraq and Jordan)
Pre-existing cases and chronic diseases -At inception date (except cancer and multi
sclerosis
- For new members, application member
shall be filled out and medical
underwriting shall be applied and
application should be filled.
Number of visits Unlimited
Coverage Umbrella Iraq and Jordan (direct billing basis)
Internationally (re-imbursement)
Pre-approval center 24/7
Maximum limit per person per annum 50000 USD for any plan (A, B & C)
The Charge Fee of Family Members Similar to Employee Fee
Duration of Selected Class without any One year from July 2020
changes from employee side

SWEDO Headquarters Country Management Office (CMO) Registration details

Tegelviksgatan 40 House Number 387 Italian Village 2, Erbil, Registration number: 802 401-6845
116 41 Stockholm, Sweden Kurdistan Region, Iraq
T: +46 (0)8 128 268 00 T: +964 (0)751 1227099
E: info@swedoaid.org E: director@swedoaid.org www.swedoaid.org
 Class A:
Chart of Price as per Employee Age:

Care Gold Class A: 100% In Hospital, 100% Out Hospital

Monthly Gross Premium per person in USD
Age Employee Confirmation
Cost Per year Cost Per month (Write Confirm)
0-17 $412 $34
18-30 $558 $46
31-45 $705 $59
46-55 $1095 $91
56-65 $1749 $146
66-99 $2238 $187

Reviewed & Agreed by:

Signature:

Employee Name:

Date:

Class B:
Chart of Price as per Employee Age:

Care Gold Class B: 100% In Hospital, 90% Out Hospital

Monthly Gross Premium per person in USD
Age Employee Confirmation
Cost Per year Cost Per month (Write Confirm)
0-17 $350 $29
18-30 $474 $40
31-45 $601 $50
46-55 $935 $78
56-65 $1495 $125
66-99 $1947 $162

Reviewed & Agreed by:

Signature:

Employee Name:

Date:

SWEDO Headquarters Country Management Office (CMO) Registration details

Tegelviksgatan 40 House Number 387 Italian Village 2, Erbil, Registration number: 802 401-6845
116 41 Stockholm, Sweden Kurdistan Region, Iraq
T: +46 (0)8 128 268 00 T: +964 (0)751 1227099
E: info@swedoaid.org E: director@swedoaid.org www.swedoaid.org
 Class C:
Chart of Price as per Employee Age:

Care Gold Class C: 100% In Hospital, 80% Out Hospital

Monthly Gross Premium per person in USD
Age Employee Confirmation
Cost Per year Cost Per month (Write Confirm)
0-17 $334 $28
18-30 $453 $38 Confirm
31-45 $575 $48
46-55 $895 $75
56-65 $1432 $119
66-99 $1874 $156

Reviewed & Agreed by:

Signature:

Employee Name: Kovan Rafiq Abdullah

Date: July 21st, 2020

Family Member Part:

The required info of family members, in case the registered employee is interested to add family members
(Husband, Wife, Daughter and Son only):

Name Relation Degree

(Husband, Wife,
Daughter or Son) Date of Birth

Additional Employee Health Insurance Form for family member should be filled by the registered employee.

Second Option: Employee has decided to bring a valid and legitimate Health insurance card
from any company that he/she prefers before 25-June-2020, otherwise the first option Class
C will be selected by the organization on behalf of employee:
Reviewed & Agreed by:

Employee Name: Date: Signature:

SWEDO Headquarters Country Management Office (CMO) Registration details

Tegelviksgatan 40 House Number 387 Italian Village 2, Erbil, Registration number: 802 401-6845
116 41 Stockholm, Sweden Kurdistan Region, Iraq
T: +46 (0)8 128 268 00 T: +964 (0)751 1227099
E: info@swedoaid.org E: director@swedoaid.org www.swedoaid.org
 Family Member Health Insurance Form
Family Member Information:
Applicant Name: Date of Birth:
Gender: Phone number:

Features of Asia Health Insurance Company for SWEDO Employees’ Family Members:

Account Manager for SWEDO Yes

Waiver of waiting period Waiver of waiting period to the existing
employee list. Waiting period shall be
applied to all members insured after
inception date. As for New enrollees,
standard terms and conditions shall be
applied.
Payment out of Iraq All over Iraq and Jordan is covered on
reimbursement basis according to the
customary rates of med net Kurdistan
Emergency (only Iraq and Jordan)
Pre-existing cases and chronic diseases -At inception date (except cancer and multi
sclerosis
- For new members, application member
shall be filled out and medical
underwriting shall be applied and
application should be filled.
Number of visits Unlimited
Coverage Umbrella Iraq and Jordan (direct billing basis)
Internationally (re-imbursement)
Pre-approval center 24/7
Maximum limit per person per annum 50000 USD for any plan (A, B & C)
The Charge Fee of Family Members Similar to Employee Fee

SWEDO Headquarters Country Management Office (CMO) Registration details

Tegelviksgatan 40 House Number 387 Italian Village 2, Erbil, Registration number: 802 401-6845
116 41 Stockholm, Sweden Kurdistan Region, Iraq
T: +46 (0)8 128 268 00 T: +964 (0)751 1227099
E: info@swedoaid.org E: director@swedoaid.org www.swedoaid.org
 Class A:
Chart of Price as per Employee Age:

Care Gold Class A: 100% In Hospital, 100% Out Hospital

Monthly Gross Premium per person in USD
Age Employee Confirmation
Cost Per year Cost Per month (Write Confirm)
0-17 $412 $34
18-30 $558 $46
31-45 $705 $59
46-55 $1095 $91
56-65 $1749 $146
66-99 $2238 $187

Reviewed & Agreed by:

Signature:

Employee Name:

Date:

Class B:
Chart of Price as per Employee Age:

Care Gold Class B: 100% In Hospital, 90% Out Hospital

Monthly Gross Premium per person in USD
Age Employee Confirmation
Cost Per year Cost Per month (Write Confirm)
0-17 $350 $29
18-30 $474 $40
31-45 $601 $50
46-55 $935 $78
56-65 $1495 $125
66-99 $1947 $162

Reviewed & Agreed by:

Signature:

Employee Name:

Date:

SWEDO Headquarters Country Management Office (CMO) Registration details

Tegelviksgatan 40 House Number 387 Italian Village 2, Erbil, Registration number: 802 401-6845
116 41 Stockholm, Sweden Kurdistan Region, Iraq
T: +46 (0)8 128 268 00 T: +964 (0)751 1227099
E: info@swedoaid.org E: director@swedoaid.org www.swedoaid.org
 Class C:
Chart of Price as per Employee Age:

Care Gold Class C: 100% In Hospital, 80% Out Hospital

Monthly Gross Premium per person in USD
Age Employee Confirmation
Cost Per year Cost Per month (Write Confirm)
0-17 $334 $28
18-30 $453 $38
31-45 $575 $48
46-55 $895 $75
56-65 $1432 $119
66-99 $1874 $156

Reviewed & Agreed by:

Signature:

Employee Name:

Date:

SWEDO Headquarters Country Management Office (CMO) Registration details

Tegelviksgatan 40 House Number 387 Italian Village 2, Erbil, Registration number: 802 401-6845
116 41 Stockholm, Sweden Kurdistan Region, Iraq
T: +46 (0)8 128 268 00 T: +964 (0)751 1227099
E: info@swedoaid.org E: director@swedoaid.org www.swedoaid.org