Unified Medical declaration form ‫ﻧ ﻤ ﻮذ ج ا ﻻ ﻓ ﺼﺎ ح اﻟ ﻄﺒ ﻲ اﻟ ﻤ ﻮ ﺣﺪ‬

Dear Insured: ‫ﻋﺰﻳﺰي اﻟﻤﺆﻣﻦ ﻟﻪ‬:

Please Fill out the form correctly for the purpose of pricing and to ensure that you and your ‫ﻧ ﺄ ﻣ ﻞ ﻗ ﻴ ﺎ ﻣ ﻚ ﺑ ﺘ ﻌ ﺒ ﺌ ﺔ ﻫ ﺬا ا ﻟ ﻨ ﻤ ﻮ ذ ج ﺑ ﺎ ﻟ ﺸ ﻜ ﻞ ا ﻟ ﺼ ﺤ ﻴ ﺢ ﻟ ﻐ ﺮ ض ا ﻟ ﺘ ﺴ ﻌ ﻴ ﺮ و ﻟ ﻀ ﻤ ﺎ ن ﺣ ﺼ ﻮ ﻟ ﻚ وأ ﻓ ﺮا د أ ﺳ ﺮ ﺗ ﻚ ﻋ ﻠ ﻰ ﺧ ﺪ ﻣ ﺎ ت‬
family receive health care services as required according to your unified policy benefit. ‫اﻟﺮﻋﺎﻳﺔ اﻟﺼﺤﻴﺔ ﺑﺎﻟﺸﻜﻞ اﻟﻤﻄﻠﻮب ﺣﺴﺐ ﻣﻨﺎﻓﻊ اﻟﻮﺛﻴﻘﺔ اﻟﻤﻮﺣﺪة‬.

Addition (2)
‫إ ﺿﺎﻓﺔ‬ New ‫ﺟﺪﻳﺪ‬ Type (1)
‫ﻧ ﻮ ع اﻟ ﻄﻠ ﺐ‬
PolicyNo./ CR 1010661978 ‫ اﻟ ﺴ ﺠ ﻞ‬/‫ر ﻗ ﻢ اﻟ ﻮﺛﻴ ﻘ ﺔ‬ Entity name: ‫ﺷ ﺮ ﻛﺔ ﺧ ﻂ إ ﻃﺎ ر اﻟ ﺼﻨﺎ ﻋﻴﺔ‬ :‫ا ﺳ ﻢ اﻟ ﻤﻨ ﺸﺄ ة‬
:‫اﻟﺘ ﺠﺎ ر ي‬
Mobile No. +966557830366 :‫ر ﻗ ﻢ اﻟ ﺠ ﻮا ل‬ Employee name: ‫ﺳ ﻤﺮ ﻓﺮ ﺣﺎ ن ﻣ ﺤ ﻤﺪ اﻟ ﺸ ﻬﺮ ي‬ :‫أ ﺳ ﻢ اﻟ ﻤ ﻮ ﻇ ﻒ‬
ID Number 1105150005 ‫رﻗ ﻢ اﻟ ﻬ ﻮﻳﺔ‬
Gender: Female :‫ اﻟﺠﻨﺲ‬Nationality:
Saudi Arabia :‫اﻟ ﺠﻨ ﺴﻴ ﺔ‬ Marital status: Married :‫اﻟ ﺤﺎﻟ ﺔ ا ﻻ ﺟﺘ ﻤﺎ ﻋﻴ ﺔ‬
Please declare any of below cases by marking under the word (Yes): ‫ﻻ‬ ‫ﻧﻌ ﻢ‬ ‫ﻓ ﻲ اﻟ ﻤ ﺮﺑﻊ ﺗ ﺤ ﺖ ﻛﻠ ﻤﺔ )ﻧ ﻌ ﻢ‬ ‫)ﻳﺮﺟﻰ اﻹﻓﺼﺎح ﻋﻦ وﺟﻮد أي ﻣﻦ اﻟﺤﺎﻻت أدﻧﺎه ﺑﻮﺿﻊ إﺷﺎرة‬:
“Below Undeclared medical case may not be covered’’ No YES "‫" ﻟﻦ ﺗﺘﻢ اﻟﺘﻐﻄﻴﺔ اﻟﺘﺄﻣﻴﻨﻴﺔ ﻟﻠﺤﺎﻻت أدﻧﺎه ﻓﻲ ﺣﺎل ﻋﺪم اﻹﻓﺼﺎح ﻋﻨﻬﺎ‬

Any hospital admission during the last 12 months "Admission: ‫ ﺗﺴﺠﻴﻞ‬:‫ ﺷﻬﺮ؟ " اﻟﺘﻨﻮﻳﻢ‬12 ‫ﻫﻞ ﺗﻢ اﻟﺘﻨﻮﻳﻢ ﺑﺎﻟﻤﺴﺘﺸﻔﻰ ﺧﻼل آﺧﺮ‬
1 registering as an admitted patient at the hospital until the ‫ﻣﻨ ٌﻮم ﻓﻲ اﻟﻤﺴﺘﺸﻔﻰ ﺣﺘﻰ ﺻﺒﺎح اﻟﻴﻮم‬
ُ ‫ا ﻟ ﺸ ﺨ ﺺ ا ﻟ ﻤ ﺆ ﻣ ﻦ ﻟ ﻪ ﻛ ﻤ ﺮﻳ ﺾ‬ 1
following morning" " ‫ا ﻟﺘ ﺎ ﻟ ﻲ‬
Have you been diagnosed with any of the following chronic
،‫ ا ﻟ ﺘ ﻮ ﺣ ﺪ ة‬: ‫ﻫ ﻞ ﺗ ﻢ ﺗ ﺸ ﺨ ﻴ ﺼ ﻚ ﺑ ﺄ ي ﻣ ﻦ ا ﻷ ﻣ ﺮا ض ا ﻟ ﻤ ﺰ ﻣ ﻨ ﺔ ا ﻟ ﺘ ﺎ ﻟ ﻴ ﺔ ﻓ ﻘ ﻂ‬
diseases Limited to: Autism, Listed Benign Tumor (Breast
tumors, fibroid uterus, benign prostatic hyperplasia, thyroid
‫ أ و را م ا ﻟ ﺮ ﺣ ﻢ‬. ‫ ا ﻷ و را م ا ﻟ ﺤ ﻤ ﻴ ﺪ ة ا ﻟ ﺘ ﺎ ﻟ ﻴ ﺔ )أ و را م ا ﻟ ﺜ ﺪ ي‬،‫ا ﻷ و را م ا ﻟ ﺴ ﺮ ﻃ ﺎﻧ ﻴ ﺔ‬
goiter and parathyroid glands, liver tumors, colon tumors),
‫ أ و را م أ و ﺗ ﻀ ﺨ ﻢ ا ﻟ ﻐ ﺪ ة ا ﻟ ﺪ ر ﻗ ﻴ ﺔ وا ﻟ ﺠ ﺎ ر‬،‫ ﺗ ﻀ ﺨ ﻢ ا ﻟ ﺒ ﺮ و ﺳ ﺘ ﺎ ت ا ﻟ ﺤ ﻤ ﻴ ﺪ‬،‫ا ﻟ ﻠ ﻴ ﻔ ﻲ‬
Malignant tumors, Listed Cardiac diseases (coronary and
‫ أ ﻣ ﺮا ض ا ﻟ ﻘ ﻠ ﺐ ا ﻟ ﺘ ﺎ ﻟ ﻴ ﺔ )أ ﻣ ﺮا ض‬، ( ‫ أ و را م ا ﻟ ﻘ ﻮ ﻟ ﻮ ن‬،‫ أ و را م ا ﻟ ﻜ ﺒ ﺪ‬،‫د ر ﻗ ﻴ ﺔ‬
valve heart disease, heart failure, cardiac fibrillation,
،‫ ا ﻟ ﺮ ﺟ ﻔ ﺎ ن ا ﻟ ﻘ ﻠ ﺒ ﻲ‬،‫ ﻓ ﺸ ﻞ ﻋ ﻀ ﻠ ﺔ ا ﻟ ﻘ ﻠ ﺐ‬،‫ﺷ ﺮاﻳ ﻴ ﻦ و ﺻ ﻤ ﺎ ﻣ ﺎ ت ا ﻟ ﻘ ﻠ ﺐ‬
2 ‫ ﺣﺼﻮات‬،(C) ‫ اﻻﻟﺘﻬﺎب اﻟﻜﺒﺪي اﻟﻔﻴﺮوﺳﻲ اﻟﻤﺰﻣﻦ ح‬،(‫وﺟﻠﻄﺎت اﻟﻘﻠﺐ‬ 2
myocardial infarction, heart clots). Chronic Hepatitis C,
Gallstones, Sever Kidney failure (stage 5 Requiring dialysis,
‫ ا ﻟ ﻔ ﺸ ﻞ ا ﻟ ﻜ ﻠ ﻮ ي ا ﻟ ﺸ ﺪﻳ ﺪ )ا ﻟ ﻤ ﺮ ﺣ ﻠ ﺔ ا ﻟ ﺨ ﺎ ﻣ ﺴ ﺔ ﻣ ﻦ أ ﻣ ﺮا ض ا ﻟ ﻜ ﻠ ﻰ‬،‫ا ﻟ ﻤ ﺮا ر ة‬
clearance of less than 15 ml/ minute*), Urinary tract stones,
/‫ ﻣﻞ‬15 ‫ اﻟﺘﺮﺷﻴﺢ اﻟﻜﻠﻮي أﻗﻞ ﻣﻦ‬،‫اﻟﺘﻲ ﺗﺴﺘﺪﻋﻲ اﻟﻐﺴﻴﻞ اﻟﻜﻠﻮي‬
‫ أ ﻣ ﺮا ض ا ﻟ ﻤ ﻨ ﺎ ﻋ ﺔ ا ﻟ ﺬاﺗ ﻴ ﺔ‬،‫ ا ﻟ ﻔ ﺘ ﻖ‬،‫ ﺣ ﺼ ﻮا ت ا ﻟ ﻤ ﺴ ﺎ ﻟ ﻚ ا ﻟ ﺒ ﻮ ﻟ ﻴ ﺔ‬،( * ‫د ﻗ ﻴ ﻘ ﺔ‬
hernias, Autoimmune diseases (lupus, rheumatoid arthritis,
psoriasis, Chrons disease, ulcerative colitis, multiple sclerosis,
،‫ ﻣ ﺮ ض ﻛ ﺮ وﻧ ﺰ‬،‫ ا ﻟ ﺼ ﺪ ﻓ ﻴ ﺔ‬،‫ وا ﻟ ﺘ ﻬ ﺎ ب ا ﻟ ﻤ ﻔ ﺎ ﺻ ﻞ ا ﻟ ﺮ و ﻣ ﺎﺗ ﺰ ﻣ ﻴ ﺔ‬،‫)ا ﻟ ﺬﺋ ﺒ ﺔ ا ﻟ ﺤ ﻤ ﺮا ء‬
( ‫ ﺣ ﺴ ﺎ ﺳ ﻴ ﺔ ا ﻟ ﻘ ﻤ ﺢ‬،‫ ا ﻟ ﺘ ﺼ ﻠ ﺐ ا ﻟ ﻠ ﻮﻳ ﺤ ﻲ‬،‫ا ﻟ ﺘ ﻬ ﺎ ب ا ﻟ ﻘ ﻮ ﻟ ﻮ ن ا ﻟ ﺘ ﻘ ﺮ ﺣ ﻲ‬
celiac disease)
Have you been diagnosed with any of the following congenital
: ‫ﻫ ﻞ ﺗ ﻢ ﺗ ﺸ ﺨ ﻴ ﺼ ﻚ ﺑ ﺄ ي ﻣ ﻦ ا ﻷ ﻣ ﺮا ض ا ﻟ ﻮ راﺛ ﻴ ﺔ أ و ا ﻟ ﺘ ﺸ ﻮ ﻫ ﺎ ت ا ﻟ ﺨ ﻠ ﻘ ﻴ ﺔ ا ﻟ ﺘ ﺎ ﻟ ﻴ ﺔ ﻓ ﻘ ﻂ‬
disorder or hereditary diseases limited to: Cerebral palsy,
‫ أ ﻣ ﺮا ض‬، ‫ ا ﻟ ﻬ ﻴ ﻤ ﻮ ﻓ ﻴ ﻠ ﻴ ﺎ‬، ‫ ا ﻟ ﺜ ﻼ ﺳ ﻴ ﻤ ﻴ ﺎ‬، ‫ ا ﺿ ﻄ ﺮا ب ا ﻟ ﺨ ﻼﻳ ﺎ ا ﻟ ﻤ ﻨ ﺠ ﻠ ﻴ ﺔ‬، ‫ا ﻟ ﺸ ﻠ ﻞ ا ﻟ ﺪ ﻣ ﺎ ﻏ ﻲ‬
Sickle cell disorder, Thalassemia, hemophilia, metabolic
‫ ﺗ ﺸ ﻮ ﻫ ﺎ ت ا ﻷ ﻋ ﻀ ﺎ ء‬، ‫ ﺿ ﻤ ﻮ ر ا ﻟ ﻌ ﻀ ﻼ ت ا ﻟ ﺸ ﻮ ﻛ ﻲ‬، ‫ ا ﺳ ﺘ ﺴ ﻘ ﺎ ء ا ﻟ ﺮأ س‬، ‫ا ﻟ ﺘ ﻤ ﺜ ﻴ ﻞ ا ﻟ ﻐ ﺬاﺋ ﻲ‬
3 diseases, Hydrocephalus, spinal muscle atrophy, genital 3
‫ ﻣ ﺮ ض ا ﻟ ﺘ ﻜ ﺴ ﺮ ا ﻟ ﻔ ﻮ ﻟ ﻲ‬، ‫ ﻣ ﺮ ض ﻏ ﻮ ﺷ ﺮ‬، ‫ أ ﻣ ﺮا ض ا ﻟ ﻜ ﺮ و ﻣ ﻮ ﺳ ﻮ ﻣ ﺎ ت‬، ‫ا ﻟ ﺘ ﻨ ﺎ ﺳ ﻠ ﻴ ﺔ‬
malformations, Chromosomal abnormalities, Gaucher’s
(G6PD) ، ،(‫ ﻣﺮض ﺗﻜﺪس اﻟﺤﺪﻳﺪ )ﻫﻴﻮﻛﺮوﻣﺎﺗﻮﺳﻴﺲ‬،‫اﻟﺘﻠﻴﻒ اﻟﻜﻴﺴﻲ ﻟﻠﺮﺋﺔ‬
disease,G6PD Deficiency, cystic fibrosis, hemochromatosis
‫ ﺗ ﻜ ﻴ ﺲ ا ﻟ ﻜ ﻠ ﻴ ﺘ ﻴ ﻦ ا ﻟ ﺨ ﻠ ﻘ ﻲ ا ﻟ ﻮ ر ا ﺛ ﻲ‬، ‫ﻣ ﺮ ض و ﻳ ﻠ ﺴ ﻮ ن‬.
,Wilson disease, Polycystic Kidney Disease.
Have you been diagnosed with any of the following eye
، ‫ ﻣ ﻴ ﺎ ه ز ر ﻗ ﺎ ء‬، ‫ ﻣ ﻴ ﺎ ه ﺑ ﻴ ﻀ ﺎ ء‬: ‫ﻫ ﻞ ﺗ ﻢ ﺗ ﺸ ﺨ ﻴ ﺼ ﻚ ﺑ ﺄ ي ﻣ ﻦ أ ﻣ ﺮا ض ا ﻟ ﻌ ﻴ ﻦ ا ﻟ ﺘ ﺎ ﻟ ﻴ ﺔ ﻓ ﻘ ﻂ‬
4 diseases limited to: Cataract, Glaucoma, Corneal diseases or 4
‫أ ﻣ ﺮا ض ا ﻟ ﻘ ﺮﻧ ﻴ ﺔ أ و أ ﻣ ﺮا ض ا ﻟ ﺸ ﺒ ﻜ ﻴ ﺔ ؟‬
Retinal diseases.
Have you been diagnosed with any of the following bone ‫ ا ﻹﻧ ﺰ ﻻ ق ا ﻟ ﻐ ﻀ ﺮ و ﻓ ﻲ‬: ‫ﻫ ﻞ ﺗ ﻢ ﺗ ﺸ ﺨ ﻴ ﺼ ﻚ ﺑ ﺄ ي ﻣ ﻦ أ ﻣ ﺮا ض ا ﻟ ﻌ ﻈ ﺎ م ا ﻟ ﺘ ﺎ ﻟ ﻴ ﺔ ﻓ ﻘ ﻂ‬
diseases limited to: Vertebral disc prolapse (moderate or ‫ اﻧ ﺤ ﺮا ف ا ﻟ ﻌ ﻤ ﻮ د ا ﻟ ﻔ ﻘ ﺮ ي ا ﻟ ﻤ ﺘ ﻮ ﺳ ﻂ أ و‬، ( ‫ا ﻟ ﻤ ﺘ ﻮ ﺳ ﻂ أ و ا ﻟ ﻤ ﺘ ﻘ ﺪ م )ا ﻟ ﺪﻳ ﺴ ﻚ‬
5 5
severe), Scoliosis (moderate or severe)**, Ligament tears, ‫ ا ﺣﺘ ﻜﺎ ك اﻟ ﻤ ﻔﺎ ﺻ ﻞ اﻟ ﻤﺘ ﻮ ﺳ ﻂ أو اﻟ ﻤﺘ ﻘ ﺪ م أو ﺗ ﻤ ﺰ ق‬،(‫اﻟ ﻤﺘ ﻘ ﺪ م * * ) ﺳ ﻜ ﻮﻟﻴ ﻮ ﺳ ﺲ‬
osteoarthritis (moderate or severe). ‫ ا ﻷ رﺑ ﻄ ﺔ‬.
Pregnant Females only: :‫ﻟ ﻸﻧﺜ ﻰ اﻟ ﺤﺎ ﻣ ﻞ ﻓ ﻘ ﻂ‬
Current single pregnancy. . ‫ﺣ ﻤ ﻞ ﺣ ﺎ ﻟ ﻲ ﺟ ﻨ ﻴ ﻦ وا ﺣ ﺪ‬
6 Current single pregnancy with previous CS delivery. . ‫ﺣ ﻤ ﻞ ﺣ ﺎ ﻟ ﻲ ﻣ ﻊ ﻗ ﻴ ﺼ ﺮﻳ ﺔ ﺳ ﺎﺑ ﻘ ﺔ‬ 6
Current multiple pregnancy. . ‫ﺣ ﻤ ﻞ ﺣ ﺎ ﻟ ﻲ ﻣﺘ ﻌ ﺪ د ا ﻷ ﺟﻨ ﺔ‬
Expected delivery date: : ‫ﺗ ﺎ رﻳ ﺦ ا ﻟ ﻮ ﻻ د ة ا ﻟ ﻤ ﺘ ﻮ ﻗ ﻊ‬
Employee and dependents details that need to be added (3) (3) ‫ﺑﻴﺎﻧﺎت اﻟﻤﻮﻇﻒ واﻓﺮاد اﻟﻌﺎﺋﻠﺔ اﻟﻤﺮاد اﺿﺎﻓﺘﻬﻢ‬

In case of a Yes answer above, please declare the case in the table below ‫ ا ﻟ ﺮ ﺟ ﺎ ء ذ ﻛ ﺮ ا ﻟ ﺤ ﺎ ﻟ ﺔ ﻓ ﻲ ا ﻟ ﺠ ﺪ و ل أ دﻧ ﺎ ه‬، ‫ﻓ ﻲ ﺣ ﺎ ﻟ ﺔ ا ﻹ ﺟ ﺎﺑ ﺔ ﺑ ﻨ ﻌ ﻢ أ ﻋ ﻼ ه‬
‫ا ﺳ ﻢ ﻣ ﻘﺪ م اﻟ ﺨﺪﻣﺔ‬ ‫اﻟ ﺤﺎﻟﺔ‬ ‫ر ﻗ ﻢ اﻟ ﺠ ﻮا ل‬ ‫اﻟ ﻄ ﻮ ل‬ ‫اﻟ ﻮ ز ن‬ ‫رﻗ ﻢ اﻟ ﻬ ﻮﻳﺔ‬ ‫اﻟ ﻘ ﺮاﺑ ﺔ‬ ‫اﻟ ﺠﻨ ﺲ‬ ‫ا ﻓ ﺮا د اﻟ ﻌﺎﺋﻠ ﺔ‬/ ‫ا ﺳ ﻢ اﻟ ﻤ ﻮ ﻇ ﻒ‬
‫م‬
Provider Name case Mobile No. Height Weight ID Number Relation Gender Employees/Dependent Name
+966557830366 1105150005 Employee Female ‫ﺳ ﻤ ﺮ ﻓ ﺮ ﺣﺎ ن ﻣ ﺤ ﻤ ﺪ اﻟ ﺸ ﻬ ﺮ ي‬ 1
Undertakings:

1. I hereby undertake that all above information are correct and the acceptance :‫ا ﻹ ﻗ ﺮا ر واﻟﺘ ﻔ ﻮﻳ ﺾ‬
of my enrolment will be on the basis of such information and that () has the
‫أ ﻗ ﺮ أ ن ا ﻟ ﺒ ﻴ ﺎ ﻧ ﺎ ت وا ﻟ ﻤ ﻌ ﻠ ﻮ ﻣ ﺎ ت ا ﻟ ﻤ ﺬ ﻛ ﻮ ر ة أ ﻋ ﻼ ه ﻛ ﺎ ﻣ ﻠ ﺔ و ﺻ ﺤ ﻴ ﺤ ﺔ و ﺑ ﻨ ﺎ ء ﻋ ﻠ ﻴ ﻪ ﻓ ﺈ ن ﻗ ﺒ ﻮ ل ا ﻟ ﻄ ﻠ ﺐ ﺳ ﻴ ﺘ ﻢ‬ .1
right to contact the hospital(s) I deal with to collect any medical information
‫ﻋ ﻠ ﻰ أ ﺳ ﺎ س ﻫ ﺬ ه ا ﻟ ﺒ ﻴ ﺎ ﻧ ﺎ ت وأ ن ﺷ ﺮ ﻛ ﺔ ) ( ﻟ ﻬ ﺎ ا ﻟ ﺤ ﻖ ﻓ ﻲ ا ﻻ ﺗ ﺼ ﺎ ل ﺑ ﺎ ﻟ ﻤ ﺴ ﺘ ﺸ ﻔ ﻴ ﺎ ت ا ﻟ ﺘ ﻲ أ ﺗ ﻌ ﺎ ﻣ ﻞ ﻣ ﻌ ﻬ ﺎ‬
needed to assess the risk(s).
.‫ﻟ ﺘ ﺰ وﻳ ﺪ ﻫ ﺎ ﺑ ﺄ ي ﻣ ﻌﻠ ﻮ ﻣ ﺎ ت ﻃ ﺒ ﻴ ﺔ ﻗ ﺪ ﺗ ﺤ ﺘ ﺎ ج إ ﻟ ﻴ ﻬ ﺎ ﻟ ﺘ ﻘ ﻴ ﻴ ﻢ ا ﻟ ﻤ ﺨ ﺎ ﻃ ﺮ‬
2. I agree that () has the right to reject the coverage/claims in full in case of no
‫أ وا ﻓ ﻖ ﻋ ﻠ ﻰ أ ﺣ ﻘ ﻴ ﺔ ) ( ﻓ ﻲ ر ﻓ ﺾ ا ﻟ ﻤ ﻄ ﺎ ﻟ ﺒ ﺔ أ و ا ﻟ ﺘ ﻐ ﻄ ﻴ ﺔ ﻛ ﻠ ﻴ ﺎ ً ﻋ ﻨ ﺪ ﻋ ﺪ م ا ﻻ ﻓ ﺼ ﺎ ح ﻋ ﻦ و ﺟ ﻮ د أ ي ﻣ ﻦ‬ .2
declaration of any cases prior to the contractual date or before enrolling or
‫اﻟ ﺤﺎ ﻻ ت اﻟ ﻤﺬ ﻛ ﻮ ر ة أ ﻋ ﻼ ه اﻟﺘ ﻲ ﻧ ﺸﺄ ت ﻗﺒ ﻞ ﺗﺎ رﻳ ﺦ اﻟﺘﻌﺎﻗﺪ أ و ﻗﺒ ﻞ ﺗ ﺴ ﺠﻴ ﻞ أ و إ ﺿﺎﻓ ﺔ ﻣ ﺆ ﻣ ﻦ ﻟ ﻪ ﺧ ﻼ ل‬
adding a new Insured during the contract.
.‫ﻓﺘ ﺮ ة ﺳ ﺮﻳﺎ ن اﻟﻌﻘﺪ‬
3. I hereby confirm reading and understanding all points presented in this form
‫أ ﻗ ﺮ ﺑ ﺄ ﻧ ﻲ ﻗ ﺪ ﻗ ﺮأ ت و ﻓ ﻬ ﻤ ﺖ ﺟ ﻤ ﻴ ﻊ ﻣ ﺎ ﺟ ﺎ ء ﻓ ﻲ ﻫ ﺬا ا ﻟ ﻨ ﻤ ﻮ ذ ج ﻛ ﻤ ﺎ أ ﺗ ﻌ ﻬ ﺪ ﺑ ﺄ ن ﻋ ﺪ م إ ﺷ ﺎ ر ﺗ ﻲ أ ﻣ ﺎ م أ ي ﻣ ﻦ‬ .3
and I agree that not marking any case is understood as "Nothing requires
.‫ا ﻟ ﺤ ﺎ ﻻ ت ا ﻟ ﻤ ﺬ ﻛ ﻮ ر ة أ ﻋ ﻼ ه ﻳ ﻌ ﺘ ﺒ ﺮ ﺑ ﻤ ﺜ ﺎﺑ ﺔ ﻧ ﻔ ﻲ و ﺟ ﻮ د ﻣ ﺎﻳ ﺴ ﺘ ﺤ ﻖ ا ﻹ ﻓ ﺼ ﺎ ح ﻋ ﻨ ﻪ و ﻋﻠ ﻴ ﻪ أ و ﻗ ﻊ‬
declaration" and I sign on these basis.
. ‫ﻋ ﺪ م ﺗ ﻌ ﺒ ﺌ ﺔ ﺑ ﻴ ﺎ ﻧ ﺎ ت ا ﻟ ﻄ ﻮ ل وا ﻟ ﻮ ز ن ﺳ ﻴ ﺆ د ي إ ﻟ ﻰ ر ﻓ ﺾ ﺗ ﻐ ﻄ ﻴ ﺔ ﺗ ﻜ ﺎ ﻟ ﻴ ﻒ ﻋ ﻤ ﻠ ﻴ ﺔ ﺟ ﺮا ﺣ ﺔ ا ﻟ ﺴ ﻤ ﻨ ﺔ ا ﻟ ﻤ ﻔ ﺮ ﻃ ﺔ‬ .4
4. Failure to fill the weight and height information will result in refusal to cover
the cost of obesity surgery.

Entity s stamp ‫ﺧﺘﻢ ﺟﻬﺔ اﻟﻌﻤﻞ‬ Employee Signature (4)

‫ﺗ ﻮ ﻗﻴ ﻊ اﻟ ﻤ ﻮ ﻇ ﻒ‬ Date ‫اﻟﺘﺎرﻳﺦ‬
17/01/2024

(1)Upon renewal of the policy, the insurer shall not request a declaration form for any insured who has .‫( أﺷﻬﺮ‬11) ‫(ﻋﻨﺪ ﺗﺠﺪﻳﺪ اﻟﻮﺛﻴﻘﺔ ﻓﺈﻧﻪ ﻻ ﻳﺤﻖ ﻟﻠﺸﺮﻛﺔ ﻃﻠﺐ ﻧﻤﻮذج إﻓﺼﺎح ﻷي ﻣﺆﻣﻦ ﻟﻪ ﻣﻀﻰ ﻋﻠﻴﻪ‬1)
been insured for 11 months.

(2)The company is not entitled to request a medical declaration form for newborns when they are added to ‫(ﻻ ﻳﺤﻖ ﻟﺸﺮﻛﺔ اﻟﺘﺄﻣﻴﻦ ﻃﻠﺐ ﻧﻤﻮذج إﻓﺼﺎح ﻃﺒﻲ ﻟﻠﻤﻮاﻟﻴﺪ اﻟﺠﺪد ﻋﻨﺪ إﺿﺎﻓﺘﻬﻢ ﻋﻠﻰ وﺛﻴﻘﺔ اﻟﺘﺄﻣﻴﻦ اﻟﺼﺤﻲ اﻟﺴﺎرﻳﺔ ﻟﻨﻔﺲ ﺷﺮﻛﺔ‬2)
the existing health insurance policy in the same insurance company unless the mother is covered on .‫ا ﻟ ﺘ ﺄ ﻣ ﻴ ﻦ ﻣ ﺎ ﻟ ﻢ ﺗ ﻜ ﻦ ا ﻷ م ﻋ ﻠ ﻰ وﺛ ﻴ ﻘ ﺔ ﺗ ﺄ ﻣ ﻴ ﻦ ا ﺧ ﺮ ى‬
different insurance company.

(3)The irregularity of the signature of the employer instead of the employee to avoid taking legal .‫(ﻓﻲ ﺣﺎل اﻟﺤﺎﺟﺔ ﻹﺿﺎﻓﺔ ﺗﺎﺑﻌﻴﻦ أﻛﺜﺮ ﻳﺘﻢ ﺗﻌﺒﺌﺔ ﻧﻤﻮذج ﺟﺪﻳﺪ‬3)
responsibility..

(4)Insurance company has the right to reject coverage of. .‫(ﻳﺤﻖ ﻟﺸﺮﻛﺔ اﻟﺘﺄﻣﻴﻦ رﻓﺾ ﺣﺎﻻت ﻋﺪم اﻹﻓﺼﺎح ﻟﻠﻌﻠﺔ اﻟﻤﺘﻌﻠﻘﺔ ﺑﺎﻟﺒﻨﻮد اﻟﻤﺬﻛﻮرة ﺑﺎﻟﻨﻤﻮذج‬4)

* As per the Kidney Foundation Kidney Disease Outcomes Quality Initiative (KDOQI) Clinical Practice .( KDOQI) ‫*وﻓﻘﺎ ﻟﺘﺼﻨﻴﻒ اﻟﺼﺎدر ﻋﻦ ﻣﺆﺳﺴﺔ ﻧﺘﺎﺋﺞ أﻣﺮاض اﻟﻜﻠﻰ وﻣﺒﺎدرة اﻟﺠﻮدة‬
Guidelines classification.

** Scoliosis Cobb angle more than 10 degrees or Scoliometer more than 5 degrees. .‫ درﺟﺎت‬5 ‫ درﺟﺎت أو ﺳﻜﻮﻟﻴﻮﻣﺘﺮ أﻛﺜﺮ ﻣﻦ‬10 ‫** ﺟﻨﻒ ﻛﻮب ﺑﺰاوﻳﺔ أﻛﺜﺮ ﻣﻦ‬