INDIVIDUAL AND FAMILY APPLICATION CHECKLIST (UAE)

How to Apply
Completing the application form should only take a few minutes.
Once completed, you can simply scan and email the copy to me together with
the following mandatory documents to process all on your behalf:

Required for all the members in the policy

Passport Copy
Visa Copy
Emirates ID copy (Front & Back)
Passport Sized Photo in JPEG format
Medical Reports (if applicable)

Please note that cards and policies cannot be activated until

the insurer received all the documents and payments.

I confirm that I have received and read the applicable Policy Wording.

I would like to receive information about (check all that are appropriate):

Critical Illness Cover Home Insurance Life Insurance

Contact Us:
Dubai Administration Office Unit 1001, Platinum Tower, Cluster I, JLT, Dubai - UAE +971 (0) 4 279 3800
Hong Kong Unit 1-11, 35th Floor, One Hung To Road, Hong Kong +852 3113 2112
Shanghai 19th Floor, 1329 Huai Hai Zhong Road, Shanghai 200031 +86 (0)21 6445 4592
Singapore 09-02A China Square Central, 18 Cross Street, Singapore +65 6536 6173

Pacific Prime is a division of Medstar Insurance Brokers LLC who are regulated and licensed by the UAE Insurance Authority (license number 12) and the Health Authority of Abu Dhabi.
In the Middle East plans are sold locally by Medstar Insurance Brokers LLC and administered by Pacific Prime ME.

REF:2018-02
 Medical Application Form
RELATION SEX MARITAL HEIGHT WEIGHT EMIRATES
NAME D. O. B
(E/S/C) (M/F) STATUS (CM) (KG) (VISA)
PRINCIPLE
SPOUSE
CHILD
CHILD
CHILD

Email ID Mobile number

Have your health insurance request was ever declined or accepted on substandard terms?
If yes, then please provide details. Yes No
Is there any eligible family member kept away from this insurance request? Yes No
If yes, then please provide details
Please answer all questions mentioned below as either Yes or No:
No. Details Declaration
1. Are you under any medical observation/undergoing any medical/ surgical/ treatment or have been advised for the same? Yes No
Do you have any chronic illness?
A chronic condition is defined as a disease, illness, or injury that has one or more of the following characteristics:
2. It needs ongoing or long-term monitoring through consultations, examinations, check-ups, and /or tests. Yes No
It needs ongoing or long-term control or relief of symptoms.
It may require rehabilitation or the patient to be trained to cope with it.
It continues indefinitely. Symptoms / medical condition may recur or likely to recur.

3. Are you taking any medication (pharmaceutical/alternative medicine) or have been advised? Yes No

4. Do you have any physical problems/ disability for which you are undergoing physiotherapy or have been advised for? Yes No

5. Have you been admitted in the hospital in the last 10 years? Yes No

Are you currently pregnant or show signs and symptoms of pregnancy or planning to get pregnant? (This question apply
6. only to married females) Yes No
If the answer to above is YES kindly fill the attached supplementary maternity questionnaire.

7. Do you have any previous surgical history or are you advised to undergo any kind of surgeries in the near future? Yes No

8. Have you been ever diagnosed/treated and cured or undergoing treatments for cancer? Yes No

Is there any other medical condition or disorder or any symptoms that you should be declared, and you are unable to relate
9. Yes No
to the above-mentioned Questions?

 Any applicant who is above 60 years of age should mandatorily submit a medical health certificate from a UAE based
Registered Medical Practitioner even if there are no medical declarations to be made on the MAF.

 Have you availed insurance services under MedNet earlier? If yes please provide earlier policy/card numbers with last
year of service:

Please fill below details if you have answered any question as “YES” from above.

- Please specify name of the patient:

- Medical Condition / Diagnosis:

(if we have more than one sickness please use another form)

- Diagnosis status: Cured / No Symptoms Ongoing Symptoms Ongoing Hospitalization Pending Hospitalization
Ongoing treatment Pending treatment

- Treatment taken as: Out-Patient Hospitalization Treated both ways Operated on Date:

- Can the illness be described as follows? Acute Chronic Recurrent

- Please specify the medication generic names, the brand name as well as the daily/weekly quantity:

- In case you are suffering from hypertension, please specify your recent Systolic and Diastolic readings below:
o Systolic:
o Diastolic:

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- In case of diabetes, please specify whether insulin dependent, also specify/attach latest HbA1c result. Yes No . HbA1c:

Based on above declarations, insurer reserves the right to request for additional medical report/documents to complete the assessment of medical conditions.

False declaration shall result in no coverage and cancellation of the insurance policy

I agree that no indemnity will be paid under the proposed insurance policy for medical expenses arising from disorders which were declared prior to
completion of this Application and which were not disclosed to the insurer at the date of this application. Failure to disclose material information to
the insurer will invalidate the proposed insurance policy.
I hereby agree, with this in respect to both, myself and my Dependents that I am aware of the general terms of this insurance and I accept them for
myself and on behalf of my dependents. I, the undersigned declare that all the above information as well as all declarations on the additional
questionnaire (personal information) are true and complete. This information shall be considered as an integral part of the insurance policy.

I hereby provide my Insurer and associated Third party administrator( MedNet) with full authorization to review my medical records across all
hospitals and/or medical centers which I have ever visited whether before or after my insurance inception date. This includes all kinds of medical
records whether related to services done on cash basis or under other insurance coverage. I acknowledge that the coverage decision for any service
requested will be based on my records review and it is the sole authority of MedNet to approve or deny the case as per the audit findings.

Date: Signature:

Supplementary Pregnancy Questionnaire

If you are currently pregnant please answer the below questions.

Name of the Pregnant Female:

Last Menstrual period date :

Do you have earlier history of Caesarean Section, Premature Delivery or Premature babies? Or any other complications related to
maternity, till date?

Have you undergone any treatment or taken any medications for infertility to achieve this pregnancy?

Please send a copy of the latest ultrasound report and specify if there are any abnormal findings or more than one foetus seen.

Do you have any of the below conditions?

Medical Condition YES / NO

Any Heart Disease or hypertension Yes No
Autoimmune Diseases Yes No
Diabetes/gestational diabetes Yes No
Thyroid Diseases Yes No
Kidney Diseases Yes No
Any placenta problems with the current pregnancy Yes No

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 Any episode of vaginal bleeding with this pregnancy Yes No

If answer to any of the above is yes please support with relevant medical records and detailed information on the same.

Disclaimer: I understand and acknowledge any pregnancy not declared at the time of this application’s coverage will be at the sole
discretion of the insurer. The insurer has the right to not cover any maternity claims to any undeclared pregnancy. I also
acknowledge and understand any pregnancy, which arises within forty calendar days from the date of this application; coverage will
also be at the discretion of the insurer.

Name:__________________________________________

Signature:________________________________________

Date: ____________________________________________

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 Pacific Prime Medstar - Orient

Pacific Prime Medstar Insurance Brokers LLC is one of the world’s largest
international private medical insurance (IPMI) Intermediaries and we work with all the
leading international insurance companies globally. We have worked successfully with
Orient for a number of years and we are finding their plans to be some of the best ‘value
for money’ IPMI plans in the market today, offering extremely competitive premiums
considering the high level of coverage presented.

From our experience, prices and service can change over time and so far we have
found Orient to be a reliable insurer, however, we feel it is important to let our clients
know that we believe the premiums and benefits offered may not be sustainable in the
long term. We would expect that there may be an increase in premium, or reduction of
benefits, for these plans in the future to bring them more in line with the current market
standards.

We feel it is important to make you aware that one of the key factors allowing Orient to
offer premiums that are considerably lower than other plans on the market is that the
claims that are made on the plan may affect the cost of the plan at your renewal.

At Pacific Prime, we are dedicated to ensuring that our clients make the most informed
decision possible and by way of this we wish to ensure that you, our valued client, are
fully aware of all possible aspects of this plan in the future. We have a long term
dedication to providing you with the best assistance with your international medical
insurance.

Name & Signature Date

Contact Information
Why do we need this? We are here to assist you in the long term, with support on all administration, renewal and claims issues.
We request this form to be completed so we can contact you/your next of kin in case of emergencies or urgent policy issues.
People often forget to update their policy details when they move house or change employer and the below information helps
us to manage your policy better.
Please help us to achieve this by keeping us fully informed of any future changes in your contact details as soon as possible.
Pacific Prime guarantees your privacy, only using this information internally regarding issues relating to your, or your family’s,
personal insurance; will not provide this information to any third parties for commercial reasons.

Policyholder Spouse
Mr Mrs Ms Miss Other: Mr Mrs Ms Miss Other:
Family Name: Family Name:
Given Name: Given Name:
MiddleName(s): MiddleName(s):
Country: Country:
Home Address: Home Address:

Contact info in the country you now live in Contact info in the country you now live in
Mobile: Mobile:
Home: Home:
Work: Work:
Personal email (1): Personal email (1):
Personal email (2): Personal email (2):
Work email: Work email:
Employer: Employer:
Country: Country:
Employers Address: Employers Address:

Permanent contact information

Country: Country:
Mobile: Mobile:
Home/Work: Home/Work:
Email: Email:

Facebook:
Twitter:
Skype:
Google+:

Emergency Contact Person

In the event of an emergency whereby we are unable to contact you or your spouse or should you be
incapacitated then please provide us with the permanent contact details of an immediate family member
who we should contact in this situation.
Family Name: Email:
Given Name: Relationship to you:
MiddleName(s): Country:
Mobile: Home Address:
Home:
Work:
 Pacific Prime Insurance Brokers LLC
Room 110, The Offices
at Ibn Battuta Gate, Dubai
PO Box 391195
04 279 3800

THIRD PARTY AUTHORIZATION FORM

At Pacific Prime we are committed to handling your data in the most appropriate manner based on your
requirements. As standard practice, where there is communication relating to a specific member of the
policy who is over the age of 18, conversations would be had with that specific member where the subject
matter is related to them.

In this instance, we would require the below form completing in order to have the ability to contact insured
members over the age of 18. In its absence we will revert to the policy holder with whom conversation
have been had leading up to the inception of the policy.

1. Policyholder Details
Name:
Policy Number:
Contact Number:

2. Over 18 Dependent communication request

Spouse:
Name:
Email address:
Contact telephone number:
Signature:

Dependent 1:
Name:
Email address:
Contact telephone number:

Signature:

Dependent 2:
Name:
Email address:
Contact telephone number:

Signature:

Authorization
This authorization is valid with effect from: (DD/MM/YYYY).

Pacific Prime Insurance Brokers LLC is regulated and licensed by the UAE Insurance Authority (license number 266)