‫ﻧﻤﻮﺫﺝ ﺍﻻﻓﺼﺎﺡ ﺍﻟﻄﺒﻲ ﺍﻟﻤﻮﺣﺪ‬

Unified Medical Declaration Form

Product Code: A-MLTH-2-C-08-014
Dear Insured: ‫ﻋﺰﻳﺰﻱ ﺍﻟﻤﺆﻣﻦ ﻟﻪ‬
Please Fill out the form correctly for the purpose of pricing and to ensured that you and your ‫ﻧﺄﻣﻞ ﻗﻴﺎﻣﻚ ﺑﺘﻌﺒﺌﺔ ﻫﺬﺍ ﺍﻟﻨﻤﻮﺫﺝ ﺑﺎﻟﺸﻜﻞ ﺍﻟﺼﺤﻴﺢ ﻟﻐﺮﺽ ﺍﻟﺘﺴﻌﻴﺮ ﻭﻟﻀﻤﺎﻥ ﺣﺼﻮﻟﻚ ﻭﺃﻓﺮﺍﺩ ﺃﺳﺮﺗﻚ ﻋﻠﻰ ﺧﺪﻣﺎﺕ‬
family receive health care services as required according to your unfied policy benefit ‫ﺍﻟﺮﻋﺎﻳﺔ ﺍﻟﺼﺤﻴﺔ ﺑﺎﻟﺸﻜﻞ ﺍﻟﻤﻄﻠﻮﺏ ﺣﺴﺐ ﻣﻨﺎﻓﻊ ﺍﻟﻮﺛﻴﻘﺔ ﺍﻟﻤﻮﺣﺪﺓ‬

Addition ‫ﺇﺿﺎﻓﺔ‬ New ‫ﺟﺪﻳﺪ‬ Type ‫ﻧﻮﻉ ﺍﻟﻄﻠﺐ‬

CR No 7011507360 ‫ﺍﻟﺴﺠﻞ ﺍﻟﺘﺠﺎﺭﻱ‬ Entity Name HADDAJ AL HIJAZ EST ‫ﺃﺳﻢ ﺍﻟﻤﻨﺸﺄﺓ‬
Mobile No 0509300773 ‫ﺭﻗﻢ ﺍﻟﺠﻮﺍﻝ‬ Khalid Ateeq Suryan Alsulami ‫ﺍﺳﻢ ﺍﻟﻤﻮﻇﻒ‬
ID Number 1 0 8 0 2 8 7 1 4 5 ‫ﺭﻗﻢ ﺍﻟﻬﻮﻳﺔ‬
Male / ‫ﺫﻛﺮ‬ Saudi Arabia
Gender ‫ ﺍﻟﺠﻨﺲ‬Nationality ‫ ﺍﻟﺠﻨﺴﻴﺔ‬Marital status Married * ‫ﻣﺘﺰﻭﺝ‬ Single R ‫ﺃﻋﺰﺏ‬ ‫ﺍﻟﺤﺎﻟﺔ ﺍﻻﺟﺘﻤﺎﻋﻴﺔ‬
Please declare any of the below cases by marking P under the word Yes ‫ ﻓﻲ ﺍﻟﻤﺮﺑﻊ ﺗﺤﺖ ﻛﻠﻤﺔ ﻧﻌﻢ‬P ‫ﻳﺮﺟﻰ ﺍﻹﻓﺼﺎﺡ ﻋﻦ ﻭﺟﻮﺩ ﺃﻱ ﻣﻦ ﺍﻟﺤﺎﻻﺕ ﺍﺩﻧﺎﻩ ﺑﻮﺿﻊ ﺇﺷﺎﺭﺓ‬
"Below Undeclared Medical Case May Not Be Covered" No / ‫ﻻ‬ Yes / ‫ﻧﻌـﻢ‬ "‫"ﻟﻦ ﺗﺘﻢ ﺍﻟﺘﻐﻄﻴﺔ ﺍﻟﺘﺄﻣﻴﻨﻴﺔ ﻟﻠﺤﺎﻻﺕ ﺃﺩﻧﺎﻩ ﻓﻰ ﺣﺎﻝ ﻋﺪﻡ ﺍﻹﻓﺼﺎﺡ ﻋﻨﻬﺎ‬
Any hospital admission during last 12 months. ‫ ﺷﻬﺮ‬12 ‫ﻫﻞ ﺗﻢ ﺍﻟﺘﻨﻮﻳﻢ ﺑﺎﻟﻤﺴﺘﺸﻔﻰ ﺧﻼﻝ ﺃﺧﺮ‬
"Admission: registering as an admitted patient at the hospital until the following morning "
* * " ‫ ﺗﺴﺠﻴﻞ ﺍﻟﺸﺨﺺ ﺍﻟﻤﺆﻣﻦ ﻟﻪ ﻛﻤﺮﻳﺾ ﻣﻨﻮﻡ ﻓﻲ ﺍﻟﻤﺴﺘﺸﻔﻰ ﺣﺘﻰ ﺻﺒﺎﺡ ﺍﻟﻴﻮﻡ ﺍﻟﺘﺎﻟﻲ‬: ‫" ﺍﻟﺘﻨﻮﻳﻢ‬

Have you been diagnosed with any of the following chronic disease limited ‫ﻫﻞ ﺗﻢ ﺗﺸﺨﻴﺼﻚ ﺑﺄﻯ ﻣﻦ ﺍﻷﻣﺮﺍﺽ ﺍﻟﺘﺎﻟﻴﺔ ﻓﻘﻂ‬
to:Autism, listed Benign Tumor (Breast tumors, fibroid uterus, benign prostatic hyperplasia, ‫ﺃﻭﺭﺍﻡ ﺃﻭ‬,‫ﺗﻀﺨﻢ ﺍﻟﺒﺮﻭﺳﺘﺎﺗﺎ ﺍﻟﺤﻤﻴﺪ‬,‫ ﺃﻭﺭﺍﻡ ﺍﻟﺮﺣﻢ ﺍﻟﻠﻴﻔﻰ‬, ‫ﺍﻻﻭﺭﺍﻡ ﺍﻟﺤﻤﻴﺪﺓ ﺍﻟﺘﺎﻟﻴﺔ )ﺃﻭﺭﺍﻡ ﺍﻟﺜﺪﻯ‬,‫ﺍﻷﻭﺭﺍﻡ ﺍﻟﺴﺮﻃﺎﻧﻴﺔ‬,‫ﺍﻟﺘﻮﺣﺪ‬
thyroid goiter and parathyroid glands, live tumors, colon tumors). Malignant tumors, listed ‫ﺃﻣﺮﺍﺽ ﺍﻟﻘﻠﺐ ﺍﻟﺘﺎﻟﻴﺔ)ﺃﻣﺮﺍﺽ ﺷﺮﺍﻳﻴﻦ ﻭﺻﻤﺎﻣﺎﺕ ﺗﻀﺨﻢ ﺍﻟﻐﺪﺓ ﺍﻟﺪﺭﻗﻴﺔ‬, (‫ﺃﻭﺭﺍﻡ ﺍﻟﻘﻮﻟﻮﻥ‬, ‫ﻭﺃﻭﺭﺍﻡ ﺍﻻﻟﻜﺒﺪ‬,‫ﻭ ﺍﻟﺠﺎﺭ ﺍﻟﺪﺭﻗﻴﺔ‬
Cardiac diseases coronary and valve heart diseases, heart failure, cardiac fibrillation
myocardial infraction, heart clots). Chronic Hepatitis C. Gallstones Sever Kidney failure (stage
* * ‫ﺍﻻﻟﺘﻬﺎﺏ ﺍﻟﻜﺒﺪﻯ ﺍﻟﻔﻴﺮﻭﺳﻰ ﺍﻟﻤﺰﻣﻦ‬.( ‫ﺍﻟﺮﺟﻔﺎﻥ ﺍﻟﻘﻠﺒﻰ ﻭﺟﻠﻄﺎﺕ ﺍﻟﻘﻠﺐ‬, ‫ﻓﺸﻞ ﻋﻀﻠﺔ ﺍﻟﻘﻠﺐ‬, ‫ﺣﺼﻮﺍﺕ ﺍﻟﻤﺮﺍﺭﺓ ﺍﻟﻘﻠﺐ‬, ‫ﺝ ﻭﺳﻰ‬
,‫ ﺍﻟﺘﺮﺷﻴﺢ ﺍﻟﻜﻠﻮﻯ ﺃﻗﻞ ﻣﻦ‬,‫ ﺍﻟﻔﺸﻞ ﺍﻟﻜﻠﻮﻯﺍﻟﺸﺪﻳﺪ )ﺍﻟﻤﺮﺣﻠﺔ ﺍﻟﺨﺎﻣﺴﺔ ﻣﻦ ﺍﻣﺮﺍﺽ ﺍﻟﻜﻠﻰ ﺍﻟﺘﻰ ﺗﺴﺘﺪﻋﻰ ﺍﻟﻐﺴﻴﻞ ﺍﻟﻜﻠﻮﻯ‬15
5 Requiring dialysis, clearance of less tha 15 ml/ minute*). Urinary tract ‫ﻣﺮﺽ‬, ‫ﺩﻗﻴﻘﺔ(ﺣﺼﻮﺍﺕ ﺍﻟﻤﺴﺎﻟﻚ ﺍﻟﺒﻮﻟﻴﺔﺃﻣﺮﺍﺽ ﺍﻟﻤﻨﺎﻋﺔ ﺍﻟﺘﺎﻟﻴﺔ )ﺍﻟﺬﺋﺒﺔ ﺍﻟﺤﻤﺮﺍﺀﻭﺍﻟﺘﻬﺎﺏ ﺍﻟﻤﻔﺎﺻﻞ ﺍﻟﺮﻭﻣﺎﺗﻴﺰﻣﻴﺔﻭ ﺍﻟﺼﺪﻓﻴﺔ‬/‫ﻣﻞ‬
stones, hernias. Autoimmune disease (lupus, rheumatoid arthritis, psoriasis, Crohn's disease, ‫ﺍﻟﺘﻬﺎﺏ ﺍﻟﻘﻮﻟﻮﻥ ﺍﻟﺘﻘﺮﺣﻰ‬, ‫ﻛﺮﻭﻧﺰ‬,
ulcerative colitis,multiple sclerosis, celiac disease) ‫ﺣﺴﺎﺳﻴﺔ ﺍﻟﻘﻤﺢ‬, ‫ﺍﻟﺘﺼﻠﺐ ﺍﻟﻠﻮﻳﺤﻰ‬

Have you been diagnosed with any of the following congenital disorder or
hereditary diseases limited to: Cerebral palsy, Sickle cell disorder, Thalassemia, ‫ﻫﻞ ﺗﻢ ﺗﺸﺨﻴﺼﻚ ﺑﺄﻱ ﻣﻦ ﺍﻷﻣﺮﺍﺽ ﺍﻟﻮﺭﺍﺛﻴﺔ ﺃﻭ ﺍﻟﺘﺸﻮﻫﺎﺕ ﺍﻟﺨﻠﻘﻴﺔ ﺍﻟﺘﺎﻟﻴﺔ ﻓﻘﻂ‬
hemophilia, metabolic diseases, Hydrocephalus, spinal muscle atrophy, genital ‫ ﺿﻤﻮﺭ‬،‫ ﺃﺳﺘﺴﻘﺎﺀ ﺍﻟﺮﺃﺱ‬،‫ ﺃﻣﺮﺍﺽ ﺍﻟﺘﻤﺜﻴﻞ ﺍﻟﻐﺬﺍﺋﻲ‬،‫ ﺍﻟﻬﻴﻤﻮﻓﻴﻠﻴﺎ‬،‫ ﺍﻟﺘﻼﺳﻴﻤﻴﺎ‬،‫ﺍﺿﻄﺮﺍﺏ ﺍﻟﺨﻼﻳﺎ ﺍﻟﻤﻨﺠﻠﻴﺔ‬, ‫ﺍﻟﺸﻠﻞ ﺍﻟﺪﻣﺎﻏﻰ‬
malformations, chromosomal abnormalities. Gaucher's disease, G6PD Deficiency, cystic
fibrosis, hemochromatosis, Wilson disease. Polycystic Kidney Disease.
* * ‫ ﻣﺮﺽ ﺍﻟﺘﻜﺴﺮﺍﻟﻔﻮﻟﻰ‬،‫ ﻣﺮﺽ ﻏﻮﺷﺮ‬،‫ ﺃﻣﺮﺍﺽ ﺍﻟﻜﺮﻭﻣﻮﺳﻮﻣﺎﺕ‬،‫ ﺗﺸﻮﻫﺎﺕ ﺍﻷﻋﻀﺎﺀ ﺍﻟﺘﻨﺎﺳﻠﻴﺔ‬،‫ﺍﻟﻌﻀﻼﺕ ﺍﻟﺸﻮﻛﻲ‬
‫ﺗﻜﻴﺲ‬,‫ﻣﺮﺽ ﻭﻳﻠﺴﻮﻥ‬, (‫ ﻣﺮﺽ ﺗﻜﺪﺱ ﺍﻟﺤﺪﻳﺪ )ﻫﻴﻤﻮﻛﺮﻭﻣﺎﺗﻮﺳﻴﺲ‬،‫( ﺍﻟﺘﻠﻴﻒ ﺍﻟﻜﻴﺴﻲ ﻟﻠﺮﺋﺔ‬G6PD)
‫ﺍﻟﻜﻠﻴﺘﻴﻦ ﺍﻟﺨﻠﻔﻰ ﺍﻟﻮﺭﺍﺋﻰ‬

Have you been diagnosed with any of following eye diseases limited to: ،‫ ﻣﻴﺎﺓ ﺯﺭﻗﺎﺀ‬،‫ ﻣﻴﺎﺓ ﺑﻴﻀﺎﺀ‬:‫ﻫﻞ ﺗﻢ ﺗﺸﺨﻴﺼﻚ ﺑﺄﻱ ﻣﻦ ﺃﻣﺮﺍﺽ ﺍﻟﻌﻴﻦ ﺍﻟﺘﺎﻟﻴﺔ ﻓﻘﻂ‬
Cataract, Glaucoma, Retinal diseases. * * ‫ﺃﻣﺮﺍﺽ ﺍﻟﺸﺒﻜﻴﺔ‬
Have you been diagnosed with any of the following bone diseases limited ‫ ﺍﻹﻧﺰﻻﻕ ﺍﻟﻐﻀﺮﻭﻓﻲ‬:‫ﻫﻞ ﺗﻢ ﺗﺸﺨﻴﺼﻚ ﺑﺄﻱ ﻣﻦ ﺃﻣﺮﺍﺽ ﺍﻟﻌﻈﺎﻡ ﺍﻟﺘﺎﻟﻴﺔ ﻓﻘﻂ‬
to:Vertebral disc prolapse (moderate or severe), Scoliosis (moderate or severe)**, or ligament
tears, osteoarthritis (moderate or severe )
* * ‫ﺗﻤﺰﻕ ﺍﻷﺭﺑﻄﺔ‬،‫ﺍﻟﺘﻬﺎﺏ ﺍﻟﻤﻔﺎﺻﻞ‬،‫ﺇﻧﺤﺮﺍﻑ ﺍﻟﻌﻤﻮﺩ ﺍﻟﻔﻘﺮﻱ‬,‫ﺍﻟﺪﻳﺴﻚ‬

Pregnant Female Only ‫ﻟﻸﻧﺜﻰ ﺍﻟﺤﺎﻣﻞ ﻓﻘﻂ‬

‫ﺣﻤﻞ ﺣﺎﻟﻲ ﺟﻨﻴﻦ ﻭﺍﺣﺪ‬
Current Single Pregnancy
* *
‫ﺣﻤﻞ ﺣﺎﻟﻲ ﻣﻊ ﻗﻴﺼﺮﻳﺔ ﺳﺎﺑﻘﺔ‬
Current Single Pregnancy with Previous CS Delivery
* *
‫ﺣﻤﻞ ﺣﺎﻟﻲ ﻣﺘﻌﺪﺩ ﺍﻷﺟﻨﺔ‬
Current Multiple Pregnancy
* *
Expected delivery date .. / .. / .... ‫ﺗﺎﺭﻳﺦ ﺍﻟﻮﻻﺩﺓ ﺍﻟﻤﺘﻮﻗﻊ‬
Employee and dependents details that need to be added ‫ﺑﻴﺎﻧﺎﺕ ﺍﻟﻤﻮﻇﻒ ﻭﺃﻓﺮﺍﺩ ﺍﻟﻌﺎﺋﻠﺔ ﺍﻟﻤﺮﺍﺩ ﺇﺿﺎﻓﺘﻬﻢ‬
In case of a yes answer above, please declare the case in the table below ‫ ﺍﻟﺮﺟﺎﺀ ﺫﻛﺮ ﺍﻟﺤﺎﻟﺔ ﻓﻲ ﺍﻟﺠﺪﻭﻝ ﺃﺩﻧﺎﻩ‬،‫ﻓﻲ ﺣﺎﻟﺔ ﺍﻹﺟﺎﺑﺔ ﺑﻨﻌﻢ ﺃﻋﻼﻩ‬
‫ﺇﺳﻢ ﻣﻘﺪﻡ ﺍﻟﺨﺪﻣﺔ‬ ‫ﺍﻟﺤﺎﻟﺔ‬ ‫ﺭﻗﻢ ﺍﻟﺠﻮﺍﻝ‬ ‫ﺍﻟﻄﻮﻝ‬ ‫ﺍﻟﻮﺯﻥ‬ ‫ﺭﻗﻢ ﺍﻟﻬﻮﻳﺔ‬ ‫ﺍﻟﻘﺮﺍﺑﺔ‬ ‫ﺍﻟﺠﻨﺲ‬ ‫ ﺃﻓﺮﺍﺩ ﺍﻟﻌﺎﺋﻠﺔ‬/ ‫ﺍﺳﻢ ﺍﻟﻤﻮﻇﻒ‬ ‫ﻡ‬
1080287145 Employee Male / ‫ ﺫﻛﺮ‬Khalid Ateeq Suryan Alsulami 1
2
3
4
5
Undertakings : ‫ﺍﻹﻗﺮﺍﺭ ﻭﺍﻟﺘﻔﻮﻳﺾ‬
1- I hereby undertake that all the above information is correct and the acceptance of my ‫ﻭﺍﻟﻤﻌﻠﻮﻣﺎﺕ ﺍﻟﻤﺬﻛﻮﺭﺓ ﺃﻋﻼﻩ ﻛﺎﻣﻠﺔ ﻭﺻﺤﻴﺤﺔ ﻭﺑﻨﺎﺀ ﻋﻠﻴﻪ ﻓﺈﻥ ﻗﺒﻮﻝ ﺍﻟﻄﻠﺐ ﺳﻴﺘﻢ‬: ‫ ﺃﻗﺮ ﺃﻥ ﺍﻟﺒﻴﺎﻧﺎﺕ‬-1
enrollment will be on the basis of such information and that Malath Cooperative Insurance ‫ﻋﻠﻰ ﺃﺳﺎﺱ ﻫﺬﻩ ﺍﻟﺒﻴﺎﻧﺎﺕ ﻭﺃﻥ ﺷﺮﻛﺔ ﻣﻼﺫ ﻟﻠﺘﺄﻣﻴﻦ ﺍﻟﺘﻌﺎﻭﻧﻲ ﻟﻬﺎ ﺍﻟﺤﻖ ﻓﻲ ﺍﻻﺗﺼﺎﻝ ﺑﺎﻟﻤﺴﺘﺸﻔﻴﺎﺕ ﺍﻟﺘﻲ‬
Company has the right to contact the hospital(s) I deal with to collect any ‫ﺃﺗﻌﺎﻣﻞ ﻣﻌﻬﺎ ﻟﺘﺰﻭﻳﺪﻫﺎ ﺑﺄﻱ ﻣﻌﻠﻮﻣﺎﺕ ﻃﺒﻴﺔ ﻗﺪ ﺗﺤﺘﺎﺝ ﺇﻟﻴﻬﺎ ﻟﺘﻘﻴﻴﻢ ﺍﻟﻤﺨﺎﻃﺮ‬
medical information needed to assess the risk(s).

2- I agree that Malath Cooperative Insurance Company has the right to reject the ‫ ﺃﻭﺍﻓﻖ ﻋﻠﻰ ﺃﺣﻘﻴﺔ ﺷﺮﻛﺔ ﻣﻼﺫ ﻟﻠﺘﺄﻣﻴﻦ ﻓﻲ ﺭﻓﺾ ﺍﻟﻤﻄﺎﻟﺒﺔ ﺃﻭ ﺍﻟﺘﻐﻄﻴﺔ ﻛﻠﻴﺎ ﻋﻨﺪ ﻋﺪﻡ ﺍﻹﻓﺼﺎﺡ ﻋﻦ ﻭﺟﻮﺩ ﺃﻱ ﻣﻦ ﺍﻟﺤﺎﻻﺕ‬-2
coverage/claims in full in case of no declaration of any cases prior to the contractual date or ‫ﺍﻟﻤﺬﻛﻮﺭﺓ ﺃﻋﻼﻩ ﺍﻟﺘﻲ ﻧﺸﺄﺕ ﻗﺒﻞ ﺗﺎﺭﻳﺦ ﺍﻟﺘﻌﺎﻗﺪ ﺃﻭ ﻗﺒﻞ ﺗﺴﺠﻴﻞ ﺃﻭ ﺇﺿﺎﻓﺔ ﻋﻀﻮ ﺧﻼﻝ ﻓﺘﺮﺓ ﺳﺮﻳﺎﻥ ﺍﻟﻌﻘﺪ‬
before enrolling or adding a new member during the contract.

3- I hereby confirm reading and understanding all points presented in this form and I agree that ‫ ﺃﻗﺮﺑﺄﻧﻲ ﻗﺪ ﻗﺮﺃﺕ ﻭﻓﻬﻤﺖ ﺟﻤﻴﻊ ﻣﺎ ﺟﺎﺀ ﻓﻲ ﻫﺬﺍ ﺍﻟﻨﻤﻮﺫﺝ ﻛﻤﺎ ﺃﺗﻌﻬﺪ ﺑﺄﻥ ﻋﺪﻡ ﺇﺷﺎﺭﺗﻲ ﺃﻣﺎﻡ ﺃﻱ ﻣﻦ‬-3
not marking any case is understood as “Nothing requires declaration” and I sign on these ‫ﺍﻟﺤﺎﻻﺕ ﺍﻟﻤﺬﻛﻮﺭﺓ ﺃﻋﻼﻩ ﻳﻌﺘﺒﺮ ﺑﻤﺜﺎﺑﺔ ﻧﻔﻲ ﻭﺟﻮﺩ ﻣﺎﻳﺴﺘﺤﻖ ﺍﻹﻓﺼﺎﺡ ﻋﻨﻪ ﻭﻋﻠﻴﻪ ﺃﻭﻗﻊ‬
basis.
4- Failure to fill the weight and height information will result in refusal to cover
the cost of obesity surgery. ‫ ﻋﺪﻡ ﺗﻌﺒﺌﺔ ﺑﻴﺎﻧﺎﺕ ﺍﻟﻄﻮﻝ ﻭﺍﻟﻮﺯﻥ ﺳﻴﺆﺩﻱ ﺇﻟﻰ ﺭﻓﺾ ﺗﻐﻄﻴﺔ ﺗﻜﺎﻟﻴﻒ ﻋﻤﻠﻴﺔ ﺟﺮﺍﺣﺔ ﺍﻟﺴﻤﻨﺔ ﺍﻟﻤﻔﺮﻃﺔ‬-4

Entity's stamp ‫ﺧﺘﻢ ﺟﻬﺔ ﺍﻟﻌﻤﻞ‬ Insured Signature ‫ﺗﻮﻗﻴﻊ ﺍﻟﻤﻮﻇﻒ‬ Date ‫ﺍﻟﺘﺎﺭﻳﺦ‬
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New_Health_Insurance.rdf Page 1 of 39 V.20 13-DEC-2023 01:30 PM

 ‫ﻧﻤﻮﺫﺝ ﺍﻻﻓﺼﺎﺡ ﺍﻟﻄﺒﻲ ﺍﻟﻤﻮﺣﺪ‬
Unified Medical Declaration Form
Product Code: A-MLTH-2-C-08-014
Dear Insured: ‫ﻋﺰﻳﺰﻱ ﺍﻟﻤﺆﻣﻦ ﻟﻪ‬
Please Fill out the form correctly for the purpose of pricing and to ensured that you and your ‫ﻧﺄﻣﻞ ﻗﻴﺎﻣﻚ ﺑﺘﻌﺒﺌﺔ ﻫﺬﺍ ﺍﻟﻨﻤﻮﺫﺝ ﺑﺎﻟﺸﻜﻞ ﺍﻟﺼﺤﻴﺢ ﻟﻐﺮﺽ ﺍﻟﺘﺴﻌﻴﺮ ﻭﻟﻀﻤﺎﻥ ﺣﺼﻮﻟﻚ ﻭﺃﻓﺮﺍﺩ ﺃﺳﺮﺗﻚ ﻋﻠﻰ ﺧﺪﻣﺎﺕ‬
family receive health care services as required according to your unfied policy benefit ‫ﺍﻟﺮﻋﺎﻳﺔ ﺍﻟﺼﺤﻴﺔ ﺑﺎﻟﺸﻜﻞ ﺍﻟﻤﻄﻠﻮﺏ ﺣﺴﺐ ﻣﻨﺎﻓﻊ ﺍﻟﻮﺛﻴﻘﺔ ﺍﻟﻤﻮﺣﺪﺓ‬

Addition ‫ﺇﺿﺎﻓﺔ‬ New ‫ﺟﺪﻳﺪ‬ Type ‫ﻧﻮﻉ ﺍﻟﻄﻠﺐ‬

CR No 7011507360 ‫ﺍﻟﺴﺠﻞ ﺍﻟﺘﺠﺎﺭﻱ‬ Entity Name HADDAJ AL HIJAZ EST ‫ﺃﺳﻢ ﺍﻟﻤﻨﺸﺄﺓ‬
Mobile No 0509300773 ‫ﺭﻗﻢ ﺍﻟﺠﻮﺍﻝ‬ Abdulrahman Faiz Marzooq Alsulami ‫ﺍﺳﻢ ﺍﻟﻤﻮﻇﻒ‬
ID Number 1 1 2 1 5 9 2 6 1 0 ‫ﺭﻗﻢ ﺍﻟﻬﻮﻳﺔ‬
Male / ‫ﺫﻛﺮ‬ Saudi Arabia
Gender ‫ ﺍﻟﺠﻨﺲ‬Nationality ‫ ﺍﻟﺠﻨﺴﻴﺔ‬Marital status Married * ‫ﻣﺘﺰﻭﺝ‬ Single R ‫ﺃﻋﺰﺏ‬ ‫ﺍﻟﺤﺎﻟﺔ ﺍﻻﺟﺘﻤﺎﻋﻴﺔ‬
Please declare any of the below cases by marking P under the word Yes ‫ ﻓﻲ ﺍﻟﻤﺮﺑﻊ ﺗﺤﺖ ﻛﻠﻤﺔ ﻧﻌﻢ‬P ‫ﻳﺮﺟﻰ ﺍﻹﻓﺼﺎﺡ ﻋﻦ ﻭﺟﻮﺩ ﺃﻱ ﻣﻦ ﺍﻟﺤﺎﻻﺕ ﺍﺩﻧﺎﻩ ﺑﻮﺿﻊ ﺇﺷﺎﺭﺓ‬
"Below Undeclared Medical Case May Not Be Covered" No / ‫ﻻ‬ Yes / ‫ﻧﻌـﻢ‬ "‫"ﻟﻦ ﺗﺘﻢ ﺍﻟﺘﻐﻄﻴﺔ ﺍﻟﺘﺄﻣﻴﻨﻴﺔ ﻟﻠﺤﺎﻻﺕ ﺃﺩﻧﺎﻩ ﻓﻰ ﺣﺎﻝ ﻋﺪﻡ ﺍﻹﻓﺼﺎﺡ ﻋﻨﻬﺎ‬
Any hospital admission during last 12 months. ‫ ﺷﻬﺮ‬12 ‫ﻫﻞ ﺗﻢ ﺍﻟﺘﻨﻮﻳﻢ ﺑﺎﻟﻤﺴﺘﺸﻔﻰ ﺧﻼﻝ ﺃﺧﺮ‬
"Admission: registering as an admitted patient at the hospital until the following morning "
* * " ‫ ﺗﺴﺠﻴﻞ ﺍﻟﺸﺨﺺ ﺍﻟﻤﺆﻣﻦ ﻟﻪ ﻛﻤﺮﻳﺾ ﻣﻨﻮﻡ ﻓﻲ ﺍﻟﻤﺴﺘﺸﻔﻰ ﺣﺘﻰ ﺻﺒﺎﺡ ﺍﻟﻴﻮﻡ ﺍﻟﺘﺎﻟﻲ‬: ‫" ﺍﻟﺘﻨﻮﻳﻢ‬

Have you been diagnosed with any of the following chronic disease limited ‫ﻫﻞ ﺗﻢ ﺗﺸﺨﻴﺼﻚ ﺑﺄﻯ ﻣﻦ ﺍﻷﻣﺮﺍﺽ ﺍﻟﺘﺎﻟﻴﺔ ﻓﻘﻂ‬
to:Autism, listed Benign Tumor (Breast tumors, fibroid uterus, benign prostatic hyperplasia, ‫ﺃﻭﺭﺍﻡ ﺃﻭ‬,‫ﺗﻀﺨﻢ ﺍﻟﺒﺮﻭﺳﺘﺎﺗﺎ ﺍﻟﺤﻤﻴﺪ‬,‫ ﺃﻭﺭﺍﻡ ﺍﻟﺮﺣﻢ ﺍﻟﻠﻴﻔﻰ‬, ‫ﺍﻻﻭﺭﺍﻡ ﺍﻟﺤﻤﻴﺪﺓ ﺍﻟﺘﺎﻟﻴﺔ )ﺃﻭﺭﺍﻡ ﺍﻟﺜﺪﻯ‬,‫ﺍﻷﻭﺭﺍﻡ ﺍﻟﺴﺮﻃﺎﻧﻴﺔ‬,‫ﺍﻟﺘﻮﺣﺪ‬
thyroid goiter and parathyroid glands, live tumors, colon tumors). Malignant tumors, listed ‫ﺃﻣﺮﺍﺽ ﺍﻟﻘﻠﺐ ﺍﻟﺘﺎﻟﻴﺔ)ﺃﻣﺮﺍﺽ ﺷﺮﺍﻳﻴﻦ ﻭﺻﻤﺎﻣﺎﺕ ﺗﻀﺨﻢ ﺍﻟﻐﺪﺓ ﺍﻟﺪﺭﻗﻴﺔ‬, (‫ﺃﻭﺭﺍﻡ ﺍﻟﻘﻮﻟﻮﻥ‬, ‫ﻭﺃﻭﺭﺍﻡ ﺍﻻﻟﻜﺒﺪ‬,‫ﻭ ﺍﻟﺠﺎﺭ ﺍﻟﺪﺭﻗﻴﺔ‬
Cardiac diseases coronary and valve heart diseases, heart failure, cardiac fibrillation
myocardial infraction, heart clots). Chronic Hepatitis C. Gallstones Sever Kidney failure (stage
* * ‫ﺍﻻﻟﺘﻬﺎﺏ ﺍﻟﻜﺒﺪﻯ ﺍﻟﻔﻴﺮﻭﺳﻰ ﺍﻟﻤﺰﻣﻦ‬.( ‫ﺍﻟﺮﺟﻔﺎﻥ ﺍﻟﻘﻠﺒﻰ ﻭﺟﻠﻄﺎﺕ ﺍﻟﻘﻠﺐ‬, ‫ﻓﺸﻞ ﻋﻀﻠﺔ ﺍﻟﻘﻠﺐ‬, ‫ﺣﺼﻮﺍﺕ ﺍﻟﻤﺮﺍﺭﺓ ﺍﻟﻘﻠﺐ‬, ‫ﺝ ﻭﺳﻰ‬
,‫ ﺍﻟﺘﺮﺷﻴﺢ ﺍﻟﻜﻠﻮﻯ ﺃﻗﻞ ﻣﻦ‬,‫ ﺍﻟﻔﺸﻞ ﺍﻟﻜﻠﻮﻯﺍﻟﺸﺪﻳﺪ )ﺍﻟﻤﺮﺣﻠﺔ ﺍﻟﺨﺎﻣﺴﺔ ﻣﻦ ﺍﻣﺮﺍﺽ ﺍﻟﻜﻠﻰ ﺍﻟﺘﻰ ﺗﺴﺘﺪﻋﻰ ﺍﻟﻐﺴﻴﻞ ﺍﻟﻜﻠﻮﻯ‬15
5 Requiring dialysis, clearance of less tha 15 ml/ minute*). Urinary tract ‫ﻣﺮﺽ‬, ‫ﺩﻗﻴﻘﺔ(ﺣﺼﻮﺍﺕ ﺍﻟﻤﺴﺎﻟﻚ ﺍﻟﺒﻮﻟﻴﺔﺃﻣﺮﺍﺽ ﺍﻟﻤﻨﺎﻋﺔ ﺍﻟﺘﺎﻟﻴﺔ )ﺍﻟﺬﺋﺒﺔ ﺍﻟﺤﻤﺮﺍﺀﻭﺍﻟﺘﻬﺎﺏ ﺍﻟﻤﻔﺎﺻﻞ ﺍﻟﺮﻭﻣﺎﺗﻴﺰﻣﻴﺔﻭ ﺍﻟﺼﺪﻓﻴﺔ‬/‫ﻣﻞ‬
stones, hernias. Autoimmune disease (lupus, rheumatoid arthritis, psoriasis, Crohn's disease, ‫ﺍﻟﺘﻬﺎﺏ ﺍﻟﻘﻮﻟﻮﻥ ﺍﻟﺘﻘﺮﺣﻰ‬, ‫ﻛﺮﻭﻧﺰ‬,
ulcerative colitis,multiple sclerosis, celiac disease) ‫ﺣﺴﺎﺳﻴﺔ ﺍﻟﻘﻤﺢ‬, ‫ﺍﻟﺘﺼﻠﺐ ﺍﻟﻠﻮﻳﺤﻰ‬

Have you been diagnosed with any of the following congenital disorder or
hereditary diseases limited to: Cerebral palsy, Sickle cell disorder, Thalassemia, ‫ﻫﻞ ﺗﻢ ﺗﺸﺨﻴﺼﻚ ﺑﺄﻱ ﻣﻦ ﺍﻷﻣﺮﺍﺽ ﺍﻟﻮﺭﺍﺛﻴﺔ ﺃﻭ ﺍﻟﺘﺸﻮﻫﺎﺕ ﺍﻟﺨﻠﻘﻴﺔ ﺍﻟﺘﺎﻟﻴﺔ ﻓﻘﻂ‬
hemophilia, metabolic diseases, Hydrocephalus, spinal muscle atrophy, genital ‫ ﺿﻤﻮﺭ‬،‫ ﺃﺳﺘﺴﻘﺎﺀ ﺍﻟﺮﺃﺱ‬،‫ ﺃﻣﺮﺍﺽ ﺍﻟﺘﻤﺜﻴﻞ ﺍﻟﻐﺬﺍﺋﻲ‬،‫ ﺍﻟﻬﻴﻤﻮﻓﻴﻠﻴﺎ‬،‫ ﺍﻟﺘﻼﺳﻴﻤﻴﺎ‬،‫ﺍﺿﻄﺮﺍﺏ ﺍﻟﺨﻼﻳﺎ ﺍﻟﻤﻨﺠﻠﻴﺔ‬, ‫ﺍﻟﺸﻠﻞ ﺍﻟﺪﻣﺎﻏﻰ‬
malformations, chromosomal abnormalities. Gaucher's disease, G6PD Deficiency, cystic
fibrosis, hemochromatosis, Wilson disease. Polycystic Kidney Disease.
* * ‫ ﻣﺮﺽ ﺍﻟﺘﻜﺴﺮﺍﻟﻔﻮﻟﻰ‬،‫ ﻣﺮﺽ ﻏﻮﺷﺮ‬،‫ ﺃﻣﺮﺍﺽ ﺍﻟﻜﺮﻭﻣﻮﺳﻮﻣﺎﺕ‬،‫ ﺗﺸﻮﻫﺎﺕ ﺍﻷﻋﻀﺎﺀ ﺍﻟﺘﻨﺎﺳﻠﻴﺔ‬،‫ﺍﻟﻌﻀﻼﺕ ﺍﻟﺸﻮﻛﻲ‬
‫ﺗﻜﻴﺲ‬,‫ﻣﺮﺽ ﻭﻳﻠﺴﻮﻥ‬, (‫ ﻣﺮﺽ ﺗﻜﺪﺱ ﺍﻟﺤﺪﻳﺪ )ﻫﻴﻤﻮﻛﺮﻭﻣﺎﺗﻮﺳﻴﺲ‬،‫( ﺍﻟﺘﻠﻴﻒ ﺍﻟﻜﻴﺴﻲ ﻟﻠﺮﺋﺔ‬G6PD)
‫ﺍﻟﻜﻠﻴﺘﻴﻦ ﺍﻟﺨﻠﻔﻰ ﺍﻟﻮﺭﺍﺋﻰ‬

Have you been diagnosed with any of following eye diseases limited to: ،‫ ﻣﻴﺎﺓ ﺯﺭﻗﺎﺀ‬،‫ ﻣﻴﺎﺓ ﺑﻴﻀﺎﺀ‬:‫ﻫﻞ ﺗﻢ ﺗﺸﺨﻴﺼﻚ ﺑﺄﻱ ﻣﻦ ﺃﻣﺮﺍﺽ ﺍﻟﻌﻴﻦ ﺍﻟﺘﺎﻟﻴﺔ ﻓﻘﻂ‬
Cataract, Glaucoma, Retinal diseases. * * ‫ﺃﻣﺮﺍﺽ ﺍﻟﺸﺒﻜﻴﺔ‬
Have you been diagnosed with any of the following bone diseases limited ‫ ﺍﻹﻧﺰﻻﻕ ﺍﻟﻐﻀﺮﻭﻓﻲ‬:‫ﻫﻞ ﺗﻢ ﺗﺸﺨﻴﺼﻚ ﺑﺄﻱ ﻣﻦ ﺃﻣﺮﺍﺽ ﺍﻟﻌﻈﺎﻡ ﺍﻟﺘﺎﻟﻴﺔ ﻓﻘﻂ‬
to:Vertebral disc prolapse (moderate or severe), Scoliosis (moderate or severe)**, or ligament
tears, osteoarthritis (moderate or severe )
* * ‫ﺗﻤﺰﻕ ﺍﻷﺭﺑﻄﺔ‬،‫ﺍﻟﺘﻬﺎﺏ ﺍﻟﻤﻔﺎﺻﻞ‬،‫ﺇﻧﺤﺮﺍﻑ ﺍﻟﻌﻤﻮﺩ ﺍﻟﻔﻘﺮﻱ‬,‫ﺍﻟﺪﻳﺴﻚ‬

Pregnant Female Only ‫ﻟﻸﻧﺜﻰ ﺍﻟﺤﺎﻣﻞ ﻓﻘﻂ‬

‫ﺣﻤﻞ ﺣﺎﻟﻲ ﺟﻨﻴﻦ ﻭﺍﺣﺪ‬
Current Single Pregnancy
* *
‫ﺣﻤﻞ ﺣﺎﻟﻲ ﻣﻊ ﻗﻴﺼﺮﻳﺔ ﺳﺎﺑﻘﺔ‬
Current Single Pregnancy with Previous CS Delivery
* *
‫ﺣﻤﻞ ﺣﺎﻟﻲ ﻣﺘﻌﺪﺩ ﺍﻷﺟﻨﺔ‬
Current Multiple Pregnancy
* *
Expected delivery date .. / .. / .... ‫ﺗﺎﺭﻳﺦ ﺍﻟﻮﻻﺩﺓ ﺍﻟﻤﺘﻮﻗﻊ‬
Employee and dependents details that need to be added ‫ﺑﻴﺎﻧﺎﺕ ﺍﻟﻤﻮﻇﻒ ﻭﺃﻓﺮﺍﺩ ﺍﻟﻌﺎﺋﻠﺔ ﺍﻟﻤﺮﺍﺩ ﺇﺿﺎﻓﺘﻬﻢ‬
In case of a yes answer above, please declare the case in the table below ‫ ﺍﻟﺮﺟﺎﺀ ﺫﻛﺮ ﺍﻟﺤﺎﻟﺔ ﻓﻲ ﺍﻟﺠﺪﻭﻝ ﺃﺩﻧﺎﻩ‬،‫ﻓﻲ ﺣﺎﻟﺔ ﺍﻹﺟﺎﺑﺔ ﺑﻨﻌﻢ ﺃﻋﻼﻩ‬
‫ﺇﺳﻢ ﻣﻘﺪﻡ ﺍﻟﺨﺪﻣﺔ‬ ‫ﺍﻟﺤﺎﻟﺔ‬ ‫ﺭﻗﻢ ﺍﻟﺠﻮﺍﻝ‬ ‫ﺍﻟﻄﻮﻝ‬ ‫ﺍﻟﻮﺯﻥ‬ ‫ﺭﻗﻢ ﺍﻟﻬﻮﻳﺔ‬ ‫ﺍﻟﻘﺮﺍﺑﺔ‬ ‫ﺍﻟﺠﻨﺲ‬ ‫ ﺃﻓﺮﺍﺩ ﺍﻟﻌﺎﺋﻠﺔ‬/ ‫ﺍﺳﻢ ﺍﻟﻤﻮﻇﻒ‬ ‫ﻡ‬
1121592610 Employee Male / ‫ ﺫﻛﺮ‬Abdulrahman Faiz Marzooq Al 1
2
3
4
5
Undertakings : ‫ﺍﻹﻗﺮﺍﺭ ﻭﺍﻟﺘﻔﻮﻳﺾ‬
1- I hereby undertake that all the above information is correct and the acceptance of my ‫ﻭﺍﻟﻤﻌﻠﻮﻣﺎﺕ ﺍﻟﻤﺬﻛﻮﺭﺓ ﺃﻋﻼﻩ ﻛﺎﻣﻠﺔ ﻭﺻﺤﻴﺤﺔ ﻭﺑﻨﺎﺀ ﻋﻠﻴﻪ ﻓﺈﻥ ﻗﺒﻮﻝ ﺍﻟﻄﻠﺐ ﺳﻴﺘﻢ‬: ‫ ﺃﻗﺮ ﺃﻥ ﺍﻟﺒﻴﺎﻧﺎﺕ‬-1
enrollment will be on the basis of such information and that Malath Cooperative Insurance ‫ﻋﻠﻰ ﺃﺳﺎﺱ ﻫﺬﻩ ﺍﻟﺒﻴﺎﻧﺎﺕ ﻭﺃﻥ ﺷﺮﻛﺔ ﻣﻼﺫ ﻟﻠﺘﺄﻣﻴﻦ ﺍﻟﺘﻌﺎﻭﻧﻲ ﻟﻬﺎ ﺍﻟﺤﻖ ﻓﻲ ﺍﻻﺗﺼﺎﻝ ﺑﺎﻟﻤﺴﺘﺸﻔﻴﺎﺕ ﺍﻟﺘﻲ‬
Company has the right to contact the hospital(s) I deal with to collect any ‫ﺃﺗﻌﺎﻣﻞ ﻣﻌﻬﺎ ﻟﺘﺰﻭﻳﺪﻫﺎ ﺑﺄﻱ ﻣﻌﻠﻮﻣﺎﺕ ﻃﺒﻴﺔ ﻗﺪ ﺗﺤﺘﺎﺝ ﺇﻟﻴﻬﺎ ﻟﺘﻘﻴﻴﻢ ﺍﻟﻤﺨﺎﻃﺮ‬
medical information needed to assess the risk(s).

2- I agree that Malath Cooperative Insurance Company has the right to reject the ‫ ﺃﻭﺍﻓﻖ ﻋﻠﻰ ﺃﺣﻘﻴﺔ ﺷﺮﻛﺔ ﻣﻼﺫ ﻟﻠﺘﺄﻣﻴﻦ ﻓﻲ ﺭﻓﺾ ﺍﻟﻤﻄﺎﻟﺒﺔ ﺃﻭ ﺍﻟﺘﻐﻄﻴﺔ ﻛﻠﻴﺎ ﻋﻨﺪ ﻋﺪﻡ ﺍﻹﻓﺼﺎﺡ ﻋﻦ ﻭﺟﻮﺩ ﺃﻱ ﻣﻦ ﺍﻟﺤﺎﻻﺕ‬-2
coverage/claims in full in case of no declaration of any cases prior to the contractual date or ‫ﺍﻟﻤﺬﻛﻮﺭﺓ ﺃﻋﻼﻩ ﺍﻟﺘﻲ ﻧﺸﺄﺕ ﻗﺒﻞ ﺗﺎﺭﻳﺦ ﺍﻟﺘﻌﺎﻗﺪ ﺃﻭ ﻗﺒﻞ ﺗﺴﺠﻴﻞ ﺃﻭ ﺇﺿﺎﻓﺔ ﻋﻀﻮ ﺧﻼﻝ ﻓﺘﺮﺓ ﺳﺮﻳﺎﻥ ﺍﻟﻌﻘﺪ‬
before enrolling or adding a new member during the contract.

3- I hereby confirm reading and understanding all points presented in this form and I agree that ‫ ﺃﻗﺮﺑﺄﻧﻲ ﻗﺪ ﻗﺮﺃﺕ ﻭﻓﻬﻤﺖ ﺟﻤﻴﻊ ﻣﺎ ﺟﺎﺀ ﻓﻲ ﻫﺬﺍ ﺍﻟﻨﻤﻮﺫﺝ ﻛﻤﺎ ﺃﺗﻌﻬﺪ ﺑﺄﻥ ﻋﺪﻡ ﺇﺷﺎﺭﺗﻲ ﺃﻣﺎﻡ ﺃﻱ ﻣﻦ‬-3
not marking any case is understood as “Nothing requires declaration” and I sign on these ‫ﺍﻟﺤﺎﻻﺕ ﺍﻟﻤﺬﻛﻮﺭﺓ ﺃﻋﻼﻩ ﻳﻌﺘﺒﺮ ﺑﻤﺜﺎﺑﺔ ﻧﻔﻲ ﻭﺟﻮﺩ ﻣﺎﻳﺴﺘﺤﻖ ﺍﻹﻓﺼﺎﺡ ﻋﻨﻪ ﻭﻋﻠﻴﻪ ﺃﻭﻗﻊ‬
basis.
4- Failure to fill the weight and height information will result in refusal to cover
the cost of obesity surgery. ‫ ﻋﺪﻡ ﺗﻌﺒﺌﺔ ﺑﻴﺎﻧﺎﺕ ﺍﻟﻄﻮﻝ ﻭﺍﻟﻮﺯﻥ ﺳﻴﺆﺩﻱ ﺇﻟﻰ ﺭﻓﺾ ﺗﻐﻄﻴﺔ ﺗﻜﺎﻟﻴﻒ ﻋﻤﻠﻴﺔ ﺟﺮﺍﺣﺔ ﺍﻟﺴﻤﻨﺔ ﺍﻟﻤﻔﺮﻃﺔ‬-4

Entity's stamp ‫ﺧﺘﻢ ﺟﻬﺔ ﺍﻟﻌﻤﻞ‬ Insured Signature ‫ﺗﻮﻗﻴﻊ ﺍﻟﻤﻮﻇﻒ‬ Date ‫ﺍﻟﺘﺎﺭﻳﺦ‬
.. / .. / ....

New_Health_Insurance.rdf Page 2 of 39 V.20 13-DEC-2023 01:30 PM

 ‫ﻧﻤﻮﺫﺝ ﺍﻻﻓﺼﺎﺡ ﺍﻟﻄﺒﻲ ﺍﻟﻤﻮﺣﺪ‬
Unified Medical Declaration Form
Product Code: A-MLTH-2-C-08-014
Dear Insured: ‫ﻋﺰﻳﺰﻱ ﺍﻟﻤﺆﻣﻦ ﻟﻪ‬
Please Fill out the form correctly for the purpose of pricing and to ensured that you and your ‫ﻧﺄﻣﻞ ﻗﻴﺎﻣﻚ ﺑﺘﻌﺒﺌﺔ ﻫﺬﺍ ﺍﻟﻨﻤﻮﺫﺝ ﺑﺎﻟﺸﻜﻞ ﺍﻟﺼﺤﻴﺢ ﻟﻐﺮﺽ ﺍﻟﺘﺴﻌﻴﺮ ﻭﻟﻀﻤﺎﻥ ﺣﺼﻮﻟﻚ ﻭﺃﻓﺮﺍﺩ ﺃﺳﺮﺗﻚ ﻋﻠﻰ ﺧﺪﻣﺎﺕ‬
family receive health care services as required according to your unfied policy benefit ‫ﺍﻟﺮﻋﺎﻳﺔ ﺍﻟﺼﺤﻴﺔ ﺑﺎﻟﺸﻜﻞ ﺍﻟﻤﻄﻠﻮﺏ ﺣﺴﺐ ﻣﻨﺎﻓﻊ ﺍﻟﻮﺛﻴﻘﺔ ﺍﻟﻤﻮﺣﺪﺓ‬

Addition ‫ﺇﺿﺎﻓﺔ‬ New ‫ﺟﺪﻳﺪ‬ Type ‫ﻧﻮﻉ ﺍﻟﻄﻠﺐ‬

CR No 7011507360 ‫ﺍﻟﺴﺠﻞ ﺍﻟﺘﺠﺎﺭﻱ‬ Entity Name HADDAJ AL HIJAZ EST ‫ﺃﺳﻢ ﺍﻟﻤﻨﺸﺄﺓ‬
Mobile No 0507579003 ‫ﺭﻗﻢ ﺍﻟﺠﻮﺍﻝ‬ Tahir Khaliqullah - Walimohammad ‫ﺍﺳﻢ ﺍﻟﻤﻮﻇﻒ‬
ID Number 2 0 1 6 7 6 8 6 4 6 ‫ﺭﻗﻢ ﺍﻟﻬﻮﻳﺔ‬
Male / ‫ﺫﻛﺮ‬ India
Gender ‫ ﺍﻟﺠﻨﺲ‬Nationality ‫ ﺍﻟﺠﻨﺴﻴﺔ‬Marital status Married R ‫ﻣﺘﺰﻭﺝ‬ Single * ‫ﺃﻋﺰﺏ‬ ‫ﺍﻟﺤﺎﻟﺔ ﺍﻻﺟﺘﻤﺎﻋﻴﺔ‬
Please declare any of the below cases by marking P under the word Yes ‫ ﻓﻲ ﺍﻟﻤﺮﺑﻊ ﺗﺤﺖ ﻛﻠﻤﺔ ﻧﻌﻢ‬P ‫ﻳﺮﺟﻰ ﺍﻹﻓﺼﺎﺡ ﻋﻦ ﻭﺟﻮﺩ ﺃﻱ ﻣﻦ ﺍﻟﺤﺎﻻﺕ ﺍﺩﻧﺎﻩ ﺑﻮﺿﻊ ﺇﺷﺎﺭﺓ‬
"Below Undeclared Medical Case May Not Be Covered" No / ‫ﻻ‬ Yes / ‫ﻧﻌـﻢ‬ "‫"ﻟﻦ ﺗﺘﻢ ﺍﻟﺘﻐﻄﻴﺔ ﺍﻟﺘﺄﻣﻴﻨﻴﺔ ﻟﻠﺤﺎﻻﺕ ﺃﺩﻧﺎﻩ ﻓﻰ ﺣﺎﻝ ﻋﺪﻡ ﺍﻹﻓﺼﺎﺡ ﻋﻨﻬﺎ‬
Any hospital admission during last 12 months. ‫ ﺷﻬﺮ‬12 ‫ﻫﻞ ﺗﻢ ﺍﻟﺘﻨﻮﻳﻢ ﺑﺎﻟﻤﺴﺘﺸﻔﻰ ﺧﻼﻝ ﺃﺧﺮ‬
"Admission: registering as an admitted patient at the hospital until the following morning "
* * " ‫ ﺗﺴﺠﻴﻞ ﺍﻟﺸﺨﺺ ﺍﻟﻤﺆﻣﻦ ﻟﻪ ﻛﻤﺮﻳﺾ ﻣﻨﻮﻡ ﻓﻲ ﺍﻟﻤﺴﺘﺸﻔﻰ ﺣﺘﻰ ﺻﺒﺎﺡ ﺍﻟﻴﻮﻡ ﺍﻟﺘﺎﻟﻲ‬: ‫" ﺍﻟﺘﻨﻮﻳﻢ‬

Have you been diagnosed with any of the following chronic disease limited ‫ﻫﻞ ﺗﻢ ﺗﺸﺨﻴﺼﻚ ﺑﺄﻯ ﻣﻦ ﺍﻷﻣﺮﺍﺽ ﺍﻟﺘﺎﻟﻴﺔ ﻓﻘﻂ‬
to:Autism, listed Benign Tumor (Breast tumors, fibroid uterus, benign prostatic hyperplasia, ‫ﺃﻭﺭﺍﻡ ﺃﻭ‬,‫ﺗﻀﺨﻢ ﺍﻟﺒﺮﻭﺳﺘﺎﺗﺎ ﺍﻟﺤﻤﻴﺪ‬,‫ ﺃﻭﺭﺍﻡ ﺍﻟﺮﺣﻢ ﺍﻟﻠﻴﻔﻰ‬, ‫ﺍﻻﻭﺭﺍﻡ ﺍﻟﺤﻤﻴﺪﺓ ﺍﻟﺘﺎﻟﻴﺔ )ﺃﻭﺭﺍﻡ ﺍﻟﺜﺪﻯ‬,‫ﺍﻷﻭﺭﺍﻡ ﺍﻟﺴﺮﻃﺎﻧﻴﺔ‬,‫ﺍﻟﺘﻮﺣﺪ‬
thyroid goiter and parathyroid glands, live tumors, colon tumors). Malignant tumors, listed ‫ﺃﻣﺮﺍﺽ ﺍﻟﻘﻠﺐ ﺍﻟﺘﺎﻟﻴﺔ)ﺃﻣﺮﺍﺽ ﺷﺮﺍﻳﻴﻦ ﻭﺻﻤﺎﻣﺎﺕ ﺗﻀﺨﻢ ﺍﻟﻐﺪﺓ ﺍﻟﺪﺭﻗﻴﺔ‬, (‫ﺃﻭﺭﺍﻡ ﺍﻟﻘﻮﻟﻮﻥ‬, ‫ﻭﺃﻭﺭﺍﻡ ﺍﻻﻟﻜﺒﺪ‬,‫ﻭ ﺍﻟﺠﺎﺭ ﺍﻟﺪﺭﻗﻴﺔ‬
Cardiac diseases coronary and valve heart diseases, heart failure, cardiac fibrillation
myocardial infraction, heart clots). Chronic Hepatitis C. Gallstones Sever Kidney failure (stage
* * ‫ﺍﻻﻟﺘﻬﺎﺏ ﺍﻟﻜﺒﺪﻯ ﺍﻟﻔﻴﺮﻭﺳﻰ ﺍﻟﻤﺰﻣﻦ‬.( ‫ﺍﻟﺮﺟﻔﺎﻥ ﺍﻟﻘﻠﺒﻰ ﻭﺟﻠﻄﺎﺕ ﺍﻟﻘﻠﺐ‬, ‫ﻓﺸﻞ ﻋﻀﻠﺔ ﺍﻟﻘﻠﺐ‬, ‫ﺣﺼﻮﺍﺕ ﺍﻟﻤﺮﺍﺭﺓ ﺍﻟﻘﻠﺐ‬, ‫ﺝ ﻭﺳﻰ‬
,‫ ﺍﻟﺘﺮﺷﻴﺢ ﺍﻟﻜﻠﻮﻯ ﺃﻗﻞ ﻣﻦ‬,‫ ﺍﻟﻔﺸﻞ ﺍﻟﻜﻠﻮﻯﺍﻟﺸﺪﻳﺪ )ﺍﻟﻤﺮﺣﻠﺔ ﺍﻟﺨﺎﻣﺴﺔ ﻣﻦ ﺍﻣﺮﺍﺽ ﺍﻟﻜﻠﻰ ﺍﻟﺘﻰ ﺗﺴﺘﺪﻋﻰ ﺍﻟﻐﺴﻴﻞ ﺍﻟﻜﻠﻮﻯ‬15
5 Requiring dialysis, clearance of less tha 15 ml/ minute*). Urinary tract ‫ﻣﺮﺽ‬, ‫ﺩﻗﻴﻘﺔ(ﺣﺼﻮﺍﺕ ﺍﻟﻤﺴﺎﻟﻚ ﺍﻟﺒﻮﻟﻴﺔﺃﻣﺮﺍﺽ ﺍﻟﻤﻨﺎﻋﺔ ﺍﻟﺘﺎﻟﻴﺔ )ﺍﻟﺬﺋﺒﺔ ﺍﻟﺤﻤﺮﺍﺀﻭﺍﻟﺘﻬﺎﺏ ﺍﻟﻤﻔﺎﺻﻞ ﺍﻟﺮﻭﻣﺎﺗﻴﺰﻣﻴﺔﻭ ﺍﻟﺼﺪﻓﻴﺔ‬/‫ﻣﻞ‬
stones, hernias. Autoimmune disease (lupus, rheumatoid arthritis, psoriasis, Crohn's disease, ‫ﺍﻟﺘﻬﺎﺏ ﺍﻟﻘﻮﻟﻮﻥ ﺍﻟﺘﻘﺮﺣﻰ‬, ‫ﻛﺮﻭﻧﺰ‬,
ulcerative colitis,multiple sclerosis, celiac disease) ‫ﺣﺴﺎﺳﻴﺔ ﺍﻟﻘﻤﺢ‬, ‫ﺍﻟﺘﺼﻠﺐ ﺍﻟﻠﻮﻳﺤﻰ‬

Have you been diagnosed with any of the following congenital disorder or
hereditary diseases limited to: Cerebral palsy, Sickle cell disorder, Thalassemia, ‫ﻫﻞ ﺗﻢ ﺗﺸﺨﻴﺼﻚ ﺑﺄﻱ ﻣﻦ ﺍﻷﻣﺮﺍﺽ ﺍﻟﻮﺭﺍﺛﻴﺔ ﺃﻭ ﺍﻟﺘﺸﻮﻫﺎﺕ ﺍﻟﺨﻠﻘﻴﺔ ﺍﻟﺘﺎﻟﻴﺔ ﻓﻘﻂ‬
hemophilia, metabolic diseases, Hydrocephalus, spinal muscle atrophy, genital ‫ ﺿﻤﻮﺭ‬،‫ ﺃﺳﺘﺴﻘﺎﺀ ﺍﻟﺮﺃﺱ‬،‫ ﺃﻣﺮﺍﺽ ﺍﻟﺘﻤﺜﻴﻞ ﺍﻟﻐﺬﺍﺋﻲ‬،‫ ﺍﻟﻬﻴﻤﻮﻓﻴﻠﻴﺎ‬،‫ ﺍﻟﺘﻼﺳﻴﻤﻴﺎ‬،‫ﺍﺿﻄﺮﺍﺏ ﺍﻟﺨﻼﻳﺎ ﺍﻟﻤﻨﺠﻠﻴﺔ‬, ‫ﺍﻟﺸﻠﻞ ﺍﻟﺪﻣﺎﻏﻰ‬
malformations, chromosomal abnormalities. Gaucher's disease, G6PD Deficiency, cystic
fibrosis, hemochromatosis, Wilson disease. Polycystic Kidney Disease.
* * ‫ ﻣﺮﺽ ﺍﻟﺘﻜﺴﺮﺍﻟﻔﻮﻟﻰ‬،‫ ﻣﺮﺽ ﻏﻮﺷﺮ‬،‫ ﺃﻣﺮﺍﺽ ﺍﻟﻜﺮﻭﻣﻮﺳﻮﻣﺎﺕ‬،‫ ﺗﺸﻮﻫﺎﺕ ﺍﻷﻋﻀﺎﺀ ﺍﻟﺘﻨﺎﺳﻠﻴﺔ‬،‫ﺍﻟﻌﻀﻼﺕ ﺍﻟﺸﻮﻛﻲ‬
‫ﺗﻜﻴﺲ‬,‫ﻣﺮﺽ ﻭﻳﻠﺴﻮﻥ‬, (‫ ﻣﺮﺽ ﺗﻜﺪﺱ ﺍﻟﺤﺪﻳﺪ )ﻫﻴﻤﻮﻛﺮﻭﻣﺎﺗﻮﺳﻴﺲ‬،‫( ﺍﻟﺘﻠﻴﻒ ﺍﻟﻜﻴﺴﻲ ﻟﻠﺮﺋﺔ‬G6PD)
‫ﺍﻟﻜﻠﻴﺘﻴﻦ ﺍﻟﺨﻠﻔﻰ ﺍﻟﻮﺭﺍﺋﻰ‬

Have you been diagnosed with any of following eye diseases limited to: ،‫ ﻣﻴﺎﺓ ﺯﺭﻗﺎﺀ‬،‫ ﻣﻴﺎﺓ ﺑﻴﻀﺎﺀ‬:‫ﻫﻞ ﺗﻢ ﺗﺸﺨﻴﺼﻚ ﺑﺄﻱ ﻣﻦ ﺃﻣﺮﺍﺽ ﺍﻟﻌﻴﻦ ﺍﻟﺘﺎﻟﻴﺔ ﻓﻘﻂ‬
Cataract, Glaucoma, Retinal diseases. * * ‫ﺃﻣﺮﺍﺽ ﺍﻟﺸﺒﻜﻴﺔ‬
Have you been diagnosed with any of the following bone diseases limited ‫ ﺍﻹﻧﺰﻻﻕ ﺍﻟﻐﻀﺮﻭﻓﻲ‬:‫ﻫﻞ ﺗﻢ ﺗﺸﺨﻴﺼﻚ ﺑﺄﻱ ﻣﻦ ﺃﻣﺮﺍﺽ ﺍﻟﻌﻈﺎﻡ ﺍﻟﺘﺎﻟﻴﺔ ﻓﻘﻂ‬
to:Vertebral disc prolapse (moderate or severe), Scoliosis (moderate or severe)**, or ligament
tears, osteoarthritis (moderate or severe )
* * ‫ﺗﻤﺰﻕ ﺍﻷﺭﺑﻄﺔ‬،‫ﺍﻟﺘﻬﺎﺏ ﺍﻟﻤﻔﺎﺻﻞ‬،‫ﺇﻧﺤﺮﺍﻑ ﺍﻟﻌﻤﻮﺩ ﺍﻟﻔﻘﺮﻱ‬,‫ﺍﻟﺪﻳﺴﻚ‬

Pregnant Female Only ‫ﻟﻸﻧﺜﻰ ﺍﻟﺤﺎﻣﻞ ﻓﻘﻂ‬

‫ﺣﻤﻞ ﺣﺎﻟﻲ ﺟﻨﻴﻦ ﻭﺍﺣﺪ‬
Current Single Pregnancy
* *
‫ﺣﻤﻞ ﺣﺎﻟﻲ ﻣﻊ ﻗﻴﺼﺮﻳﺔ ﺳﺎﺑﻘﺔ‬
Current Single Pregnancy with Previous CS Delivery
* *
‫ﺣﻤﻞ ﺣﺎﻟﻲ ﻣﺘﻌﺪﺩ ﺍﻷﺟﻨﺔ‬
Current Multiple Pregnancy
* *
Expected delivery date .. / .. / .... ‫ﺗﺎﺭﻳﺦ ﺍﻟﻮﻻﺩﺓ ﺍﻟﻤﺘﻮﻗﻊ‬
Employee and dependents details that need to be added ‫ﺑﻴﺎﻧﺎﺕ ﺍﻟﻤﻮﻇﻒ ﻭﺃﻓﺮﺍﺩ ﺍﻟﻌﺎﺋﻠﺔ ﺍﻟﻤﺮﺍﺩ ﺇﺿﺎﻓﺘﻬﻢ‬
In case of a yes answer above, please declare the case in the table below ‫ ﺍﻟﺮﺟﺎﺀ ﺫﻛﺮ ﺍﻟﺤﺎﻟﺔ ﻓﻲ ﺍﻟﺠﺪﻭﻝ ﺃﺩﻧﺎﻩ‬،‫ﻓﻲ ﺣﺎﻟﺔ ﺍﻹﺟﺎﺑﺔ ﺑﻨﻌﻢ ﺃﻋﻼﻩ‬
‫ﺇﺳﻢ ﻣﻘﺪﻡ ﺍﻟﺨﺪﻣﺔ‬ ‫ﺍﻟﺤﺎﻟﺔ‬ ‫ﺭﻗﻢ ﺍﻟﺠﻮﺍﻝ‬ ‫ﺍﻟﻄﻮﻝ‬ ‫ﺍﻟﻮﺯﻥ‬ ‫ﺭﻗﻢ ﺍﻟﻬﻮﻳﺔ‬ ‫ﺍﻟﻘﺮﺍﺑﺔ‬ ‫ﺍﻟﺠﻨﺲ‬ ‫ ﺃﻓﺮﺍﺩ ﺍﻟﻌﺎﺋﻠﺔ‬/ ‫ﺍﺳﻢ ﺍﻟﻤﻮﻇﻒ‬ ‫ﻡ‬
2016768646 Employee Male / ‫ ﺫﻛﺮ‬Tahir Khaliqullah - Walimoham 1
2
3
4
5
Undertakings : ‫ﺍﻹﻗﺮﺍﺭ ﻭﺍﻟﺘﻔﻮﻳﺾ‬
1- I hereby undertake that all the above information is correct and the acceptance of my ‫ﻭﺍﻟﻤﻌﻠﻮﻣﺎﺕ ﺍﻟﻤﺬﻛﻮﺭﺓ ﺃﻋﻼﻩ ﻛﺎﻣﻠﺔ ﻭﺻﺤﻴﺤﺔ ﻭﺑﻨﺎﺀ ﻋﻠﻴﻪ ﻓﺈﻥ ﻗﺒﻮﻝ ﺍﻟﻄﻠﺐ ﺳﻴﺘﻢ‬: ‫ ﺃﻗﺮ ﺃﻥ ﺍﻟﺒﻴﺎﻧﺎﺕ‬-1
enrollment will be on the basis of such information and that Malath Cooperative Insurance ‫ﻋﻠﻰ ﺃﺳﺎﺱ ﻫﺬﻩ ﺍﻟﺒﻴﺎﻧﺎﺕ ﻭﺃﻥ ﺷﺮﻛﺔ ﻣﻼﺫ ﻟﻠﺘﺄﻣﻴﻦ ﺍﻟﺘﻌﺎﻭﻧﻲ ﻟﻬﺎ ﺍﻟﺤﻖ ﻓﻲ ﺍﻻﺗﺼﺎﻝ ﺑﺎﻟﻤﺴﺘﺸﻔﻴﺎﺕ ﺍﻟﺘﻲ‬
Company has the right to contact the hospital(s) I deal with to collect any ‫ﺃﺗﻌﺎﻣﻞ ﻣﻌﻬﺎ ﻟﺘﺰﻭﻳﺪﻫﺎ ﺑﺄﻱ ﻣﻌﻠﻮﻣﺎﺕ ﻃﺒﻴﺔ ﻗﺪ ﺗﺤﺘﺎﺝ ﺇﻟﻴﻬﺎ ﻟﺘﻘﻴﻴﻢ ﺍﻟﻤﺨﺎﻃﺮ‬
medical information needed to assess the risk(s).

2- I agree that Malath Cooperative Insurance Company has the right to reject the ‫ ﺃﻭﺍﻓﻖ ﻋﻠﻰ ﺃﺣﻘﻴﺔ ﺷﺮﻛﺔ ﻣﻼﺫ ﻟﻠﺘﺄﻣﻴﻦ ﻓﻲ ﺭﻓﺾ ﺍﻟﻤﻄﺎﻟﺒﺔ ﺃﻭ ﺍﻟﺘﻐﻄﻴﺔ ﻛﻠﻴﺎ ﻋﻨﺪ ﻋﺪﻡ ﺍﻹﻓﺼﺎﺡ ﻋﻦ ﻭﺟﻮﺩ ﺃﻱ ﻣﻦ ﺍﻟﺤﺎﻻﺕ‬-2
coverage/claims in full in case of no declaration of any cases prior to the contractual date or ‫ﺍﻟﻤﺬﻛﻮﺭﺓ ﺃﻋﻼﻩ ﺍﻟﺘﻲ ﻧﺸﺄﺕ ﻗﺒﻞ ﺗﺎﺭﻳﺦ ﺍﻟﺘﻌﺎﻗﺪ ﺃﻭ ﻗﺒﻞ ﺗﺴﺠﻴﻞ ﺃﻭ ﺇﺿﺎﻓﺔ ﻋﻀﻮ ﺧﻼﻝ ﻓﺘﺮﺓ ﺳﺮﻳﺎﻥ ﺍﻟﻌﻘﺪ‬
before enrolling or adding a new member during the contract.

3- I hereby confirm reading and understanding all points presented in this form and I agree that ‫ ﺃﻗﺮﺑﺄﻧﻲ ﻗﺪ ﻗﺮﺃﺕ ﻭﻓﻬﻤﺖ ﺟﻤﻴﻊ ﻣﺎ ﺟﺎﺀ ﻓﻲ ﻫﺬﺍ ﺍﻟﻨﻤﻮﺫﺝ ﻛﻤﺎ ﺃﺗﻌﻬﺪ ﺑﺄﻥ ﻋﺪﻡ ﺇﺷﺎﺭﺗﻲ ﺃﻣﺎﻡ ﺃﻱ ﻣﻦ‬-3
not marking any case is understood as “Nothing requires declaration” and I sign on these ‫ﺍﻟﺤﺎﻻﺕ ﺍﻟﻤﺬﻛﻮﺭﺓ ﺃﻋﻼﻩ ﻳﻌﺘﺒﺮ ﺑﻤﺜﺎﺑﺔ ﻧﻔﻲ ﻭﺟﻮﺩ ﻣﺎﻳﺴﺘﺤﻖ ﺍﻹﻓﺼﺎﺡ ﻋﻨﻪ ﻭﻋﻠﻴﻪ ﺃﻭﻗﻊ‬
basis.
4- Failure to fill the weight and height information will result in refusal to cover
the cost of obesity surgery. ‫ ﻋﺪﻡ ﺗﻌﺒﺌﺔ ﺑﻴﺎﻧﺎﺕ ﺍﻟﻄﻮﻝ ﻭﺍﻟﻮﺯﻥ ﺳﻴﺆﺩﻱ ﺇﻟﻰ ﺭﻓﺾ ﺗﻐﻄﻴﺔ ﺗﻜﺎﻟﻴﻒ ﻋﻤﻠﻴﺔ ﺟﺮﺍﺣﺔ ﺍﻟﺴﻤﻨﺔ ﺍﻟﻤﻔﺮﻃﺔ‬-4

Entity's stamp ‫ﺧﺘﻢ ﺟﻬﺔ ﺍﻟﻌﻤﻞ‬ Insured Signature ‫ﺗﻮﻗﻴﻊ ﺍﻟﻤﻮﻇﻒ‬ Date ‫ﺍﻟﺘﺎﺭﻳﺦ‬
.. / .. / ....

New_Health_Insurance.rdf Page 3 of 39 V.20 13-DEC-2023 01:30 PM

 ‫ﻧﻤﻮﺫﺝ ﺍﻻﻓﺼﺎﺡ ﺍﻟﻄﺒﻲ ﺍﻟﻤﻮﺣﺪ‬
Unified Medical Declaration Form
Product Code: A-MLTH-2-C-08-014
Dear Insured: ‫ﻋﺰﻳﺰﻱ ﺍﻟﻤﺆﻣﻦ ﻟﻪ‬
Please Fill out the form correctly for the purpose of pricing and to ensured that you and your ‫ﻧﺄﻣﻞ ﻗﻴﺎﻣﻚ ﺑﺘﻌﺒﺌﺔ ﻫﺬﺍ ﺍﻟﻨﻤﻮﺫﺝ ﺑﺎﻟﺸﻜﻞ ﺍﻟﺼﺤﻴﺢ ﻟﻐﺮﺽ ﺍﻟﺘﺴﻌﻴﺮ ﻭﻟﻀﻤﺎﻥ ﺣﺼﻮﻟﻚ ﻭﺃﻓﺮﺍﺩ ﺃﺳﺮﺗﻚ ﻋﻠﻰ ﺧﺪﻣﺎﺕ‬
family receive health care services as required according to your unfied policy benefit ‫ﺍﻟﺮﻋﺎﻳﺔ ﺍﻟﺼﺤﻴﺔ ﺑﺎﻟﺸﻜﻞ ﺍﻟﻤﻄﻠﻮﺏ ﺣﺴﺐ ﻣﻨﺎﻓﻊ ﺍﻟﻮﺛﻴﻘﺔ ﺍﻟﻤﻮﺣﺪﺓ‬

Addition ‫ﺇﺿﺎﻓﺔ‬ New ‫ﺟﺪﻳﺪ‬ Type ‫ﻧﻮﻉ ﺍﻟﻄﻠﺐ‬

CR No 7011507360 ‫ﺍﻟﺴﺠﻞ ﺍﻟﺘﺠﺎﺭﻱ‬ Entity Name HADDAJ AL HIJAZ EST ‫ﺃﺳﻢ ﺍﻟﻤﻨﺸﺄﺓ‬
Mobile No 0507579003 ‫ﺭﻗﻢ ﺍﻟﺠﻮﺍﻝ‬ Saeeda - - Zahirddin ‫ﺍﺳﻢ ﺍﻟﻤﻮﻇﻒ‬
ID Number 2 1 2 8 2 4 1 0 6 0 ‫ﺭﻗﻢ ﺍﻟﻬﻮﻳﺔ‬
Gender Female / ‫ﺍﻟﺠﻨﺲ ﺃﻧﺜﻰ‬ Nationality India ‫ ﺍﻟﺠﻨﺴﻴﺔ‬Marital status Married R ‫ﻣﺘﺰﻭﺝ‬ Single * ‫ﺃﻋﺰﺏ‬ ‫ﺍﻟﺤﺎﻟﺔ ﺍﻻﺟﺘﻤﺎﻋﻴﺔ‬
Please declare any of the below cases by marking P under the word Yes ‫ ﻓﻲ ﺍﻟﻤﺮﺑﻊ ﺗﺤﺖ ﻛﻠﻤﺔ ﻧﻌﻢ‬P ‫ﻳﺮﺟﻰ ﺍﻹﻓﺼﺎﺡ ﻋﻦ ﻭﺟﻮﺩ ﺃﻱ ﻣﻦ ﺍﻟﺤﺎﻻﺕ ﺍﺩﻧﺎﻩ ﺑﻮﺿﻊ ﺇﺷﺎﺭﺓ‬
"Below Undeclared Medical Case May Not Be Covered" No / ‫ﻻ‬ Yes / ‫ﻧﻌـﻢ‬ "‫"ﻟﻦ ﺗﺘﻢ ﺍﻟﺘﻐﻄﻴﺔ ﺍﻟﺘﺄﻣﻴﻨﻴﺔ ﻟﻠﺤﺎﻻﺕ ﺃﺩﻧﺎﻩ ﻓﻰ ﺣﺎﻝ ﻋﺪﻡ ﺍﻹﻓﺼﺎﺡ ﻋﻨﻬﺎ‬
Any hospital admission during last 12 months. ‫ ﺷﻬﺮ‬12 ‫ﻫﻞ ﺗﻢ ﺍﻟﺘﻨﻮﻳﻢ ﺑﺎﻟﻤﺴﺘﺸﻔﻰ ﺧﻼﻝ ﺃﺧﺮ‬
"Admission: registering as an admitted patient at the hospital until the following morning "
* * " ‫ ﺗﺴﺠﻴﻞ ﺍﻟﺸﺨﺺ ﺍﻟﻤﺆﻣﻦ ﻟﻪ ﻛﻤﺮﻳﺾ ﻣﻨﻮﻡ ﻓﻲ ﺍﻟﻤﺴﺘﺸﻔﻰ ﺣﺘﻰ ﺻﺒﺎﺡ ﺍﻟﻴﻮﻡ ﺍﻟﺘﺎﻟﻲ‬: ‫" ﺍﻟﺘﻨﻮﻳﻢ‬

Have you been diagnosed with any of the following chronic disease limited ‫ﻫﻞ ﺗﻢ ﺗﺸﺨﻴﺼﻚ ﺑﺄﻯ ﻣﻦ ﺍﻷﻣﺮﺍﺽ ﺍﻟﺘﺎﻟﻴﺔ ﻓﻘﻂ‬
to:Autism, listed Benign Tumor (Breast tumors, fibroid uterus, benign prostatic hyperplasia, ‫ﺃﻭﺭﺍﻡ ﺃﻭ‬,‫ﺗﻀﺨﻢ ﺍﻟﺒﺮﻭﺳﺘﺎﺗﺎ ﺍﻟﺤﻤﻴﺪ‬,‫ ﺃﻭﺭﺍﻡ ﺍﻟﺮﺣﻢ ﺍﻟﻠﻴﻔﻰ‬, ‫ﺍﻻﻭﺭﺍﻡ ﺍﻟﺤﻤﻴﺪﺓ ﺍﻟﺘﺎﻟﻴﺔ )ﺃﻭﺭﺍﻡ ﺍﻟﺜﺪﻯ‬,‫ﺍﻷﻭﺭﺍﻡ ﺍﻟﺴﺮﻃﺎﻧﻴﺔ‬,‫ﺍﻟﺘﻮﺣﺪ‬
thyroid goiter and parathyroid glands, live tumors, colon tumors). Malignant tumors, listed ‫ﺃﻣﺮﺍﺽ ﺍﻟﻘﻠﺐ ﺍﻟﺘﺎﻟﻴﺔ)ﺃﻣﺮﺍﺽ ﺷﺮﺍﻳﻴﻦ ﻭﺻﻤﺎﻣﺎﺕ ﺗﻀﺨﻢ ﺍﻟﻐﺪﺓ ﺍﻟﺪﺭﻗﻴﺔ‬, (‫ﺃﻭﺭﺍﻡ ﺍﻟﻘﻮﻟﻮﻥ‬, ‫ﻭﺃﻭﺭﺍﻡ ﺍﻻﻟﻜﺒﺪ‬,‫ﻭ ﺍﻟﺠﺎﺭ ﺍﻟﺪﺭﻗﻴﺔ‬
Cardiac diseases coronary and valve heart diseases, heart failure, cardiac fibrillation
myocardial infraction, heart clots). Chronic Hepatitis C. Gallstones Sever Kidney failure (stage
* * ‫ﺍﻻﻟﺘﻬﺎﺏ ﺍﻟﻜﺒﺪﻯ ﺍﻟﻔﻴﺮﻭﺳﻰ ﺍﻟﻤﺰﻣﻦ‬.( ‫ﺍﻟﺮﺟﻔﺎﻥ ﺍﻟﻘﻠﺒﻰ ﻭﺟﻠﻄﺎﺕ ﺍﻟﻘﻠﺐ‬, ‫ﻓﺸﻞ ﻋﻀﻠﺔ ﺍﻟﻘﻠﺐ‬, ‫ﺣﺼﻮﺍﺕ ﺍﻟﻤﺮﺍﺭﺓ ﺍﻟﻘﻠﺐ‬, ‫ﺝ ﻭﺳﻰ‬
,‫ ﺍﻟﺘﺮﺷﻴﺢ ﺍﻟﻜﻠﻮﻯ ﺃﻗﻞ ﻣﻦ‬,‫ ﺍﻟﻔﺸﻞ ﺍﻟﻜﻠﻮﻯﺍﻟﺸﺪﻳﺪ )ﺍﻟﻤﺮﺣﻠﺔ ﺍﻟﺨﺎﻣﺴﺔ ﻣﻦ ﺍﻣﺮﺍﺽ ﺍﻟﻜﻠﻰ ﺍﻟﺘﻰ ﺗﺴﺘﺪﻋﻰ ﺍﻟﻐﺴﻴﻞ ﺍﻟﻜﻠﻮﻯ‬15
5 Requiring dialysis, clearance of less tha 15 ml/ minute*). Urinary tract ‫ﻣﺮﺽ‬, ‫ﺩﻗﻴﻘﺔ(ﺣﺼﻮﺍﺕ ﺍﻟﻤﺴﺎﻟﻚ ﺍﻟﺒﻮﻟﻴﺔﺃﻣﺮﺍﺽ ﺍﻟﻤﻨﺎﻋﺔ ﺍﻟﺘﺎﻟﻴﺔ )ﺍﻟﺬﺋﺒﺔ ﺍﻟﺤﻤﺮﺍﺀﻭﺍﻟﺘﻬﺎﺏ ﺍﻟﻤﻔﺎﺻﻞ ﺍﻟﺮﻭﻣﺎﺗﻴﺰﻣﻴﺔﻭ ﺍﻟﺼﺪﻓﻴﺔ‬/‫ﻣﻞ‬
stones, hernias. Autoimmune disease (lupus, rheumatoid arthritis, psoriasis, Crohn's disease, ‫ﺍﻟﺘﻬﺎﺏ ﺍﻟﻘﻮﻟﻮﻥ ﺍﻟﺘﻘﺮﺣﻰ‬, ‫ﻛﺮﻭﻧﺰ‬,
ulcerative colitis,multiple sclerosis, celiac disease) ‫ﺣﺴﺎﺳﻴﺔ ﺍﻟﻘﻤﺢ‬, ‫ﺍﻟﺘﺼﻠﺐ ﺍﻟﻠﻮﻳﺤﻰ‬

Have you been diagnosed with any of the following congenital disorder or
hereditary diseases limited to: Cerebral palsy, Sickle cell disorder, Thalassemia, ‫ﻫﻞ ﺗﻢ ﺗﺸﺨﻴﺼﻚ ﺑﺄﻱ ﻣﻦ ﺍﻷﻣﺮﺍﺽ ﺍﻟﻮﺭﺍﺛﻴﺔ ﺃﻭ ﺍﻟﺘﺸﻮﻫﺎﺕ ﺍﻟﺨﻠﻘﻴﺔ ﺍﻟﺘﺎﻟﻴﺔ ﻓﻘﻂ‬
hemophilia, metabolic diseases, Hydrocephalus, spinal muscle atrophy, genital ‫ ﺿﻤﻮﺭ‬،‫ ﺃﺳﺘﺴﻘﺎﺀ ﺍﻟﺮﺃﺱ‬،‫ ﺃﻣﺮﺍﺽ ﺍﻟﺘﻤﺜﻴﻞ ﺍﻟﻐﺬﺍﺋﻲ‬،‫ ﺍﻟﻬﻴﻤﻮﻓﻴﻠﻴﺎ‬،‫ ﺍﻟﺘﻼﺳﻴﻤﻴﺎ‬،‫ﺍﺿﻄﺮﺍﺏ ﺍﻟﺨﻼﻳﺎ ﺍﻟﻤﻨﺠﻠﻴﺔ‬, ‫ﺍﻟﺸﻠﻞ ﺍﻟﺪﻣﺎﻏﻰ‬
malformations, chromosomal abnormalities. Gaucher's disease, G6PD Deficiency, cystic
fibrosis, hemochromatosis, Wilson disease. Polycystic Kidney Disease.
* * ‫ ﻣﺮﺽ ﺍﻟﺘﻜﺴﺮﺍﻟﻔﻮﻟﻰ‬،‫ ﻣﺮﺽ ﻏﻮﺷﺮ‬،‫ ﺃﻣﺮﺍﺽ ﺍﻟﻜﺮﻭﻣﻮﺳﻮﻣﺎﺕ‬،‫ ﺗﺸﻮﻫﺎﺕ ﺍﻷﻋﻀﺎﺀ ﺍﻟﺘﻨﺎﺳﻠﻴﺔ‬،‫ﺍﻟﻌﻀﻼﺕ ﺍﻟﺸﻮﻛﻲ‬
‫ﺗﻜﻴﺲ‬,‫ﻣﺮﺽ ﻭﻳﻠﺴﻮﻥ‬, (‫ ﻣﺮﺽ ﺗﻜﺪﺱ ﺍﻟﺤﺪﻳﺪ )ﻫﻴﻤﻮﻛﺮﻭﻣﺎﺗﻮﺳﻴﺲ‬،‫( ﺍﻟﺘﻠﻴﻒ ﺍﻟﻜﻴﺴﻲ ﻟﻠﺮﺋﺔ‬G6PD)
‫ﺍﻟﻜﻠﻴﺘﻴﻦ ﺍﻟﺨﻠﻔﻰ ﺍﻟﻮﺭﺍﺋﻰ‬

Have you been diagnosed with any of following eye diseases limited to: ،‫ ﻣﻴﺎﺓ ﺯﺭﻗﺎﺀ‬،‫ ﻣﻴﺎﺓ ﺑﻴﻀﺎﺀ‬:‫ﻫﻞ ﺗﻢ ﺗﺸﺨﻴﺼﻚ ﺑﺄﻱ ﻣﻦ ﺃﻣﺮﺍﺽ ﺍﻟﻌﻴﻦ ﺍﻟﺘﺎﻟﻴﺔ ﻓﻘﻂ‬
Cataract, Glaucoma, Retinal diseases. * * ‫ﺃﻣﺮﺍﺽ ﺍﻟﺸﺒﻜﻴﺔ‬
Have you been diagnosed with any of the following bone diseases limited ‫ ﺍﻹﻧﺰﻻﻕ ﺍﻟﻐﻀﺮﻭﻓﻲ‬:‫ﻫﻞ ﺗﻢ ﺗﺸﺨﻴﺼﻚ ﺑﺄﻱ ﻣﻦ ﺃﻣﺮﺍﺽ ﺍﻟﻌﻈﺎﻡ ﺍﻟﺘﺎﻟﻴﺔ ﻓﻘﻂ‬
to:Vertebral disc prolapse (moderate or severe), Scoliosis (moderate or severe)**, or ligament
tears, osteoarthritis (moderate or severe )
* * ‫ﺗﻤﺰﻕ ﺍﻷﺭﺑﻄﺔ‬،‫ﺍﻟﺘﻬﺎﺏ ﺍﻟﻤﻔﺎﺻﻞ‬،‫ﺇﻧﺤﺮﺍﻑ ﺍﻟﻌﻤﻮﺩ ﺍﻟﻔﻘﺮﻱ‬,‫ﺍﻟﺪﻳﺴﻚ‬

Pregnant Female Only ‫ﻟﻸﻧﺜﻰ ﺍﻟﺤﺎﻣﻞ ﻓﻘﻂ‬

‫ﺣﻤﻞ ﺣﺎﻟﻲ ﺟﻨﻴﻦ ﻭﺍﺣﺪ‬
Current Single Pregnancy
* *
‫ﺣﻤﻞ ﺣﺎﻟﻲ ﻣﻊ ﻗﻴﺼﺮﻳﺔ ﺳﺎﺑﻘﺔ‬
Current Single Pregnancy with Previous CS Delivery
* *
‫ﺣﻤﻞ ﺣﺎﻟﻲ ﻣﺘﻌﺪﺩ ﺍﻷﺟﻨﺔ‬
Current Multiple Pregnancy
* *
Expected delivery date .. / .. / .... ‫ﺗﺎﺭﻳﺦ ﺍﻟﻮﻻﺩﺓ ﺍﻟﻤﺘﻮﻗﻊ‬
Employee and dependents details that need to be added ‫ﺑﻴﺎﻧﺎﺕ ﺍﻟﻤﻮﻇﻒ ﻭﺃﻓﺮﺍﺩ ﺍﻟﻌﺎﺋﻠﺔ ﺍﻟﻤﺮﺍﺩ ﺇﺿﺎﻓﺘﻬﻢ‬
In case of a yes answer above, please declare the case in the table below ‫ ﺍﻟﺮﺟﺎﺀ ﺫﻛﺮ ﺍﻟﺤﺎﻟﺔ ﻓﻲ ﺍﻟﺠﺪﻭﻝ ﺃﺩﻧﺎﻩ‬،‫ﻓﻲ ﺣﺎﻟﺔ ﺍﻹﺟﺎﺑﺔ ﺑﻨﻌﻢ ﺃﻋﻼﻩ‬
‫ﺇﺳﻢ ﻣﻘﺪﻡ ﺍﻟﺨﺪﻣﺔ‬ ‫ﺍﻟﺤﺎﻟﺔ‬ ‫ﺭﻗﻢ ﺍﻟﺠﻮﺍﻝ‬ ‫ﺍﻟﻄﻮﻝ‬ ‫ﺍﻟﻮﺯﻥ‬ ‫ﺭﻗﻢ ﺍﻟﻬﻮﻳﺔ‬ ‫ﺍﻟﻘﺮﺍﺑﺔ‬ ‫ﺍﻟﺠﻨﺲ‬ ‫ ﺃﻓﺮﺍﺩ ﺍﻟﻌﺎﺋﻠﺔ‬/ ‫ﺍﺳﻢ ﺍﻟﻤﻮﻇﻒ‬ ‫ﻡ‬
2128241060 Spouse Female / ‫ ﺃﻧﺜﻰ‬Saeeda - - Zahirddin 1
2
3
4
5
Undertakings : ‫ﺍﻹﻗﺮﺍﺭ ﻭﺍﻟﺘﻔﻮﻳﺾ‬
1- I hereby undertake that all the above information is correct and the acceptance of my ‫ﻭﺍﻟﻤﻌﻠﻮﻣﺎﺕ ﺍﻟﻤﺬﻛﻮﺭﺓ ﺃﻋﻼﻩ ﻛﺎﻣﻠﺔ ﻭﺻﺤﻴﺤﺔ ﻭﺑﻨﺎﺀ ﻋﻠﻴﻪ ﻓﺈﻥ ﻗﺒﻮﻝ ﺍﻟﻄﻠﺐ ﺳﻴﺘﻢ‬: ‫ ﺃﻗﺮ ﺃﻥ ﺍﻟﺒﻴﺎﻧﺎﺕ‬-1
enrollment will be on the basis of such information and that Malath Cooperative Insurance ‫ﻋﻠﻰ ﺃﺳﺎﺱ ﻫﺬﻩ ﺍﻟﺒﻴﺎﻧﺎﺕ ﻭﺃﻥ ﺷﺮﻛﺔ ﻣﻼﺫ ﻟﻠﺘﺄﻣﻴﻦ ﺍﻟﺘﻌﺎﻭﻧﻲ ﻟﻬﺎ ﺍﻟﺤﻖ ﻓﻲ ﺍﻻﺗﺼﺎﻝ ﺑﺎﻟﻤﺴﺘﺸﻔﻴﺎﺕ ﺍﻟﺘﻲ‬
Company has the right to contact the hospital(s) I deal with to collect any ‫ﺃﺗﻌﺎﻣﻞ ﻣﻌﻬﺎ ﻟﺘﺰﻭﻳﺪﻫﺎ ﺑﺄﻱ ﻣﻌﻠﻮﻣﺎﺕ ﻃﺒﻴﺔ ﻗﺪ ﺗﺤﺘﺎﺝ ﺇﻟﻴﻬﺎ ﻟﺘﻘﻴﻴﻢ ﺍﻟﻤﺨﺎﻃﺮ‬
medical information needed to assess the risk(s).

2- I agree that Malath Cooperative Insurance Company has the right to reject the ‫ ﺃﻭﺍﻓﻖ ﻋﻠﻰ ﺃﺣﻘﻴﺔ ﺷﺮﻛﺔ ﻣﻼﺫ ﻟﻠﺘﺄﻣﻴﻦ ﻓﻲ ﺭﻓﺾ ﺍﻟﻤﻄﺎﻟﺒﺔ ﺃﻭ ﺍﻟﺘﻐﻄﻴﺔ ﻛﻠﻴﺎ ﻋﻨﺪ ﻋﺪﻡ ﺍﻹﻓﺼﺎﺡ ﻋﻦ ﻭﺟﻮﺩ ﺃﻱ ﻣﻦ ﺍﻟﺤﺎﻻﺕ‬-2
coverage/claims in full in case of no declaration of any cases prior to the contractual date or ‫ﺍﻟﻤﺬﻛﻮﺭﺓ ﺃﻋﻼﻩ ﺍﻟﺘﻲ ﻧﺸﺄﺕ ﻗﺒﻞ ﺗﺎﺭﻳﺦ ﺍﻟﺘﻌﺎﻗﺪ ﺃﻭ ﻗﺒﻞ ﺗﺴﺠﻴﻞ ﺃﻭ ﺇﺿﺎﻓﺔ ﻋﻀﻮ ﺧﻼﻝ ﻓﺘﺮﺓ ﺳﺮﻳﺎﻥ ﺍﻟﻌﻘﺪ‬
before enrolling or adding a new member during the contract.

3- I hereby confirm reading and understanding all points presented in this form and I agree that ‫ ﺃﻗﺮﺑﺄﻧﻲ ﻗﺪ ﻗﺮﺃﺕ ﻭﻓﻬﻤﺖ ﺟﻤﻴﻊ ﻣﺎ ﺟﺎﺀ ﻓﻲ ﻫﺬﺍ ﺍﻟﻨﻤﻮﺫﺝ ﻛﻤﺎ ﺃﺗﻌﻬﺪ ﺑﺄﻥ ﻋﺪﻡ ﺇﺷﺎﺭﺗﻲ ﺃﻣﺎﻡ ﺃﻱ ﻣﻦ‬-3
not marking any case is understood as “Nothing requires declaration” and I sign on these ‫ﺍﻟﺤﺎﻻﺕ ﺍﻟﻤﺬﻛﻮﺭﺓ ﺃﻋﻼﻩ ﻳﻌﺘﺒﺮ ﺑﻤﺜﺎﺑﺔ ﻧﻔﻲ ﻭﺟﻮﺩ ﻣﺎﻳﺴﺘﺤﻖ ﺍﻹﻓﺼﺎﺡ ﻋﻨﻪ ﻭﻋﻠﻴﻪ ﺃﻭﻗﻊ‬
basis.
4- Failure to fill the weight and height information will result in refusal to cover
the cost of obesity surgery. ‫ ﻋﺪﻡ ﺗﻌﺒﺌﺔ ﺑﻴﺎﻧﺎﺕ ﺍﻟﻄﻮﻝ ﻭﺍﻟﻮﺯﻥ ﺳﻴﺆﺩﻱ ﺇﻟﻰ ﺭﻓﺾ ﺗﻐﻄﻴﺔ ﺗﻜﺎﻟﻴﻒ ﻋﻤﻠﻴﺔ ﺟﺮﺍﺣﺔ ﺍﻟﺴﻤﻨﺔ ﺍﻟﻤﻔﺮﻃﺔ‬-4

Entity's stamp ‫ﺧﺘﻢ ﺟﻬﺔ ﺍﻟﻌﻤﻞ‬ Insured Signature ‫ﺗﻮﻗﻴﻊ ﺍﻟﻤﻮﻇﻒ‬ Date ‫ﺍﻟﺘﺎﺭﻳﺦ‬
.. / .. / ....

New_Health_Insurance.rdf Page 4 of 39 V.20 13-DEC-2023 01:30 PM

 ‫ﻧﻤﻮﺫﺝ ﺍﻻﻓﺼﺎﺡ ﺍﻟﻄﺒﻲ ﺍﻟﻤﻮﺣﺪ‬
Unified Medical Declaration Form
Product Code: A-MLTH-2-C-08-014
Dear Insured: ‫ﻋﺰﻳﺰﻱ ﺍﻟﻤﺆﻣﻦ ﻟﻪ‬
Please Fill out the form correctly for the purpose of pricing and to ensured that you and your ‫ﻧﺄﻣﻞ ﻗﻴﺎﻣﻚ ﺑﺘﻌﺒﺌﺔ ﻫﺬﺍ ﺍﻟﻨﻤﻮﺫﺝ ﺑﺎﻟﺸﻜﻞ ﺍﻟﺼﺤﻴﺢ ﻟﻐﺮﺽ ﺍﻟﺘﺴﻌﻴﺮ ﻭﻟﻀﻤﺎﻥ ﺣﺼﻮﻟﻚ ﻭﺃﻓﺮﺍﺩ ﺃﺳﺮﺗﻚ ﻋﻠﻰ ﺧﺪﻣﺎﺕ‬
family receive health care services as required according to your unfied policy benefit ‫ﺍﻟﺮﻋﺎﻳﺔ ﺍﻟﺼﺤﻴﺔ ﺑﺎﻟﺸﻜﻞ ﺍﻟﻤﻄﻠﻮﺏ ﺣﺴﺐ ﻣﻨﺎﻓﻊ ﺍﻟﻮﺛﻴﻘﺔ ﺍﻟﻤﻮﺣﺪﺓ‬

Addition ‫ﺇﺿﺎﻓﺔ‬ New ‫ﺟﺪﻳﺪ‬ Type ‫ﻧﻮﻉ ﺍﻟﻄﻠﺐ‬

CR No 7011507360 ‫ﺍﻟﺴﺠﻞ ﺍﻟﺘﺠﺎﺭﻱ‬ Entity Name HADDAJ AL HIJAZ EST ‫ﺃﺳﻢ ﺍﻟﻤﻨﺸﺄﺓ‬
Mobile No 0554820813 ‫ﺭﻗﻢ ﺍﻟﺠﻮﺍﻝ‬ Abdulrahman Tahir Khaleequllah Walimohammad ‫ﺍﺳﻢ ﺍﻟﻤﻮﻇﻒ‬
ID Number 2 1 6 1 6 4 3 9 4 1 ‫ﺭﻗﻢ ﺍﻟﻬﻮﻳﺔ‬
Male / ‫ﺫﻛﺮ‬ India
Gender ‫ ﺍﻟﺠﻨﺲ‬Nationality ‫ ﺍﻟﺠﻨﺴﻴﺔ‬Marital status Married * ‫ﻣﺘﺰﻭﺝ‬ Single R ‫ﺃﻋﺰﺏ‬ ‫ﺍﻟﺤﺎﻟﺔ ﺍﻻﺟﺘﻤﺎﻋﻴﺔ‬
Please declare any of the below cases by marking P under the word Yes ‫ ﻓﻲ ﺍﻟﻤﺮﺑﻊ ﺗﺤﺖ ﻛﻠﻤﺔ ﻧﻌﻢ‬P ‫ﻳﺮﺟﻰ ﺍﻹﻓﺼﺎﺡ ﻋﻦ ﻭﺟﻮﺩ ﺃﻱ ﻣﻦ ﺍﻟﺤﺎﻻﺕ ﺍﺩﻧﺎﻩ ﺑﻮﺿﻊ ﺇﺷﺎﺭﺓ‬
"Below Undeclared Medical Case May Not Be Covered" No / ‫ﻻ‬ Yes / ‫ﻧﻌـﻢ‬ "‫"ﻟﻦ ﺗﺘﻢ ﺍﻟﺘﻐﻄﻴﺔ ﺍﻟﺘﺄﻣﻴﻨﻴﺔ ﻟﻠﺤﺎﻻﺕ ﺃﺩﻧﺎﻩ ﻓﻰ ﺣﺎﻝ ﻋﺪﻡ ﺍﻹﻓﺼﺎﺡ ﻋﻨﻬﺎ‬
Any hospital admission during last 12 months. ‫ ﺷﻬﺮ‬12 ‫ﻫﻞ ﺗﻢ ﺍﻟﺘﻨﻮﻳﻢ ﺑﺎﻟﻤﺴﺘﺸﻔﻰ ﺧﻼﻝ ﺃﺧﺮ‬
"Admission: registering as an admitted patient at the hospital until the following morning "
* * " ‫ ﺗﺴﺠﻴﻞ ﺍﻟﺸﺨﺺ ﺍﻟﻤﺆﻣﻦ ﻟﻪ ﻛﻤﺮﻳﺾ ﻣﻨﻮﻡ ﻓﻲ ﺍﻟﻤﺴﺘﺸﻔﻰ ﺣﺘﻰ ﺻﺒﺎﺡ ﺍﻟﻴﻮﻡ ﺍﻟﺘﺎﻟﻲ‬: ‫" ﺍﻟﺘﻨﻮﻳﻢ‬

Have you been diagnosed with any of the following chronic disease limited ‫ﻫﻞ ﺗﻢ ﺗﺸﺨﻴﺼﻚ ﺑﺄﻯ ﻣﻦ ﺍﻷﻣﺮﺍﺽ ﺍﻟﺘﺎﻟﻴﺔ ﻓﻘﻂ‬
to:Autism, listed Benign Tumor (Breast tumors, fibroid uterus, benign prostatic hyperplasia, ‫ﺃﻭﺭﺍﻡ ﺃﻭ‬,‫ﺗﻀﺨﻢ ﺍﻟﺒﺮﻭﺳﺘﺎﺗﺎ ﺍﻟﺤﻤﻴﺪ‬,‫ ﺃﻭﺭﺍﻡ ﺍﻟﺮﺣﻢ ﺍﻟﻠﻴﻔﻰ‬, ‫ﺍﻻﻭﺭﺍﻡ ﺍﻟﺤﻤﻴﺪﺓ ﺍﻟﺘﺎﻟﻴﺔ )ﺃﻭﺭﺍﻡ ﺍﻟﺜﺪﻯ‬,‫ﺍﻷﻭﺭﺍﻡ ﺍﻟﺴﺮﻃﺎﻧﻴﺔ‬,‫ﺍﻟﺘﻮﺣﺪ‬
thyroid goiter and parathyroid glands, live tumors, colon tumors). Malignant tumors, listed ‫ﺃﻣﺮﺍﺽ ﺍﻟﻘﻠﺐ ﺍﻟﺘﺎﻟﻴﺔ)ﺃﻣﺮﺍﺽ ﺷﺮﺍﻳﻴﻦ ﻭﺻﻤﺎﻣﺎﺕ ﺗﻀﺨﻢ ﺍﻟﻐﺪﺓ ﺍﻟﺪﺭﻗﻴﺔ‬, (‫ﺃﻭﺭﺍﻡ ﺍﻟﻘﻮﻟﻮﻥ‬, ‫ﻭﺃﻭﺭﺍﻡ ﺍﻻﻟﻜﺒﺪ‬,‫ﻭ ﺍﻟﺠﺎﺭ ﺍﻟﺪﺭﻗﻴﺔ‬
Cardiac diseases coronary and valve heart diseases, heart failure, cardiac fibrillation
myocardial infraction, heart clots). Chronic Hepatitis C. Gallstones Sever Kidney failure (stage
* * ‫ﺍﻻﻟﺘﻬﺎﺏ ﺍﻟﻜﺒﺪﻯ ﺍﻟﻔﻴﺮﻭﺳﻰ ﺍﻟﻤﺰﻣﻦ‬.( ‫ﺍﻟﺮﺟﻔﺎﻥ ﺍﻟﻘﻠﺒﻰ ﻭﺟﻠﻄﺎﺕ ﺍﻟﻘﻠﺐ‬, ‫ﻓﺸﻞ ﻋﻀﻠﺔ ﺍﻟﻘﻠﺐ‬, ‫ﺣﺼﻮﺍﺕ ﺍﻟﻤﺮﺍﺭﺓ ﺍﻟﻘﻠﺐ‬, ‫ﺝ ﻭﺳﻰ‬
,‫ ﺍﻟﺘﺮﺷﻴﺢ ﺍﻟﻜﻠﻮﻯ ﺃﻗﻞ ﻣﻦ‬,‫ ﺍﻟﻔﺸﻞ ﺍﻟﻜﻠﻮﻯﺍﻟﺸﺪﻳﺪ )ﺍﻟﻤﺮﺣﻠﺔ ﺍﻟﺨﺎﻣﺴﺔ ﻣﻦ ﺍﻣﺮﺍﺽ ﺍﻟﻜﻠﻰ ﺍﻟﺘﻰ ﺗﺴﺘﺪﻋﻰ ﺍﻟﻐﺴﻴﻞ ﺍﻟﻜﻠﻮﻯ‬15
5 Requiring dialysis, clearance of less tha 15 ml/ minute*). Urinary tract ‫ﻣﺮﺽ‬, ‫ﺩﻗﻴﻘﺔ(ﺣﺼﻮﺍﺕ ﺍﻟﻤﺴﺎﻟﻚ ﺍﻟﺒﻮﻟﻴﺔﺃﻣﺮﺍﺽ ﺍﻟﻤﻨﺎﻋﺔ ﺍﻟﺘﺎﻟﻴﺔ )ﺍﻟﺬﺋﺒﺔ ﺍﻟﺤﻤﺮﺍﺀﻭﺍﻟﺘﻬﺎﺏ ﺍﻟﻤﻔﺎﺻﻞ ﺍﻟﺮﻭﻣﺎﺗﻴﺰﻣﻴﺔﻭ ﺍﻟﺼﺪﻓﻴﺔ‬/‫ﻣﻞ‬
stones, hernias. Autoimmune disease (lupus, rheumatoid arthritis, psoriasis, Crohn's disease, ‫ﺍﻟﺘﻬﺎﺏ ﺍﻟﻘﻮﻟﻮﻥ ﺍﻟﺘﻘﺮﺣﻰ‬, ‫ﻛﺮﻭﻧﺰ‬,
ulcerative colitis,multiple sclerosis, celiac disease) ‫ﺣﺴﺎﺳﻴﺔ ﺍﻟﻘﻤﺢ‬, ‫ﺍﻟﺘﺼﻠﺐ ﺍﻟﻠﻮﻳﺤﻰ‬

Have you been diagnosed with any of the following congenital disorder or
hereditary diseases limited to: Cerebral palsy, Sickle cell disorder, Thalassemia, ‫ﻫﻞ ﺗﻢ ﺗﺸﺨﻴﺼﻚ ﺑﺄﻱ ﻣﻦ ﺍﻷﻣﺮﺍﺽ ﺍﻟﻮﺭﺍﺛﻴﺔ ﺃﻭ ﺍﻟﺘﺸﻮﻫﺎﺕ ﺍﻟﺨﻠﻘﻴﺔ ﺍﻟﺘﺎﻟﻴﺔ ﻓﻘﻂ‬
hemophilia, metabolic diseases, Hydrocephalus, spinal muscle atrophy, genital ‫ ﺿﻤﻮﺭ‬،‫ ﺃﺳﺘﺴﻘﺎﺀ ﺍﻟﺮﺃﺱ‬،‫ ﺃﻣﺮﺍﺽ ﺍﻟﺘﻤﺜﻴﻞ ﺍﻟﻐﺬﺍﺋﻲ‬،‫ ﺍﻟﻬﻴﻤﻮﻓﻴﻠﻴﺎ‬،‫ ﺍﻟﺘﻼﺳﻴﻤﻴﺎ‬،‫ﺍﺿﻄﺮﺍﺏ ﺍﻟﺨﻼﻳﺎ ﺍﻟﻤﻨﺠﻠﻴﺔ‬, ‫ﺍﻟﺸﻠﻞ ﺍﻟﺪﻣﺎﻏﻰ‬
malformations, chromosomal abnormalities. Gaucher's disease, G6PD Deficiency, cystic
fibrosis, hemochromatosis, Wilson disease. Polycystic Kidney Disease.
* * ‫ ﻣﺮﺽ ﺍﻟﺘﻜﺴﺮﺍﻟﻔﻮﻟﻰ‬،‫ ﻣﺮﺽ ﻏﻮﺷﺮ‬،‫ ﺃﻣﺮﺍﺽ ﺍﻟﻜﺮﻭﻣﻮﺳﻮﻣﺎﺕ‬،‫ ﺗﺸﻮﻫﺎﺕ ﺍﻷﻋﻀﺎﺀ ﺍﻟﺘﻨﺎﺳﻠﻴﺔ‬،‫ﺍﻟﻌﻀﻼﺕ ﺍﻟﺸﻮﻛﻲ‬
‫ﺗﻜﻴﺲ‬,‫ﻣﺮﺽ ﻭﻳﻠﺴﻮﻥ‬, (‫ ﻣﺮﺽ ﺗﻜﺪﺱ ﺍﻟﺤﺪﻳﺪ )ﻫﻴﻤﻮﻛﺮﻭﻣﺎﺗﻮﺳﻴﺲ‬،‫( ﺍﻟﺘﻠﻴﻒ ﺍﻟﻜﻴﺴﻲ ﻟﻠﺮﺋﺔ‬G6PD)
‫ﺍﻟﻜﻠﻴﺘﻴﻦ ﺍﻟﺨﻠﻔﻰ ﺍﻟﻮﺭﺍﺋﻰ‬

Have you been diagnosed with any of following eye diseases limited to: ،‫ ﻣﻴﺎﺓ ﺯﺭﻗﺎﺀ‬،‫ ﻣﻴﺎﺓ ﺑﻴﻀﺎﺀ‬:‫ﻫﻞ ﺗﻢ ﺗﺸﺨﻴﺼﻚ ﺑﺄﻱ ﻣﻦ ﺃﻣﺮﺍﺽ ﺍﻟﻌﻴﻦ ﺍﻟﺘﺎﻟﻴﺔ ﻓﻘﻂ‬
Cataract, Glaucoma, Retinal diseases. * * ‫ﺃﻣﺮﺍﺽ ﺍﻟﺸﺒﻜﻴﺔ‬
Have you been diagnosed with any of the following bone diseases limited ‫ ﺍﻹﻧﺰﻻﻕ ﺍﻟﻐﻀﺮﻭﻓﻲ‬:‫ﻫﻞ ﺗﻢ ﺗﺸﺨﻴﺼﻚ ﺑﺄﻱ ﻣﻦ ﺃﻣﺮﺍﺽ ﺍﻟﻌﻈﺎﻡ ﺍﻟﺘﺎﻟﻴﺔ ﻓﻘﻂ‬
to:Vertebral disc prolapse (moderate or severe), Scoliosis (moderate or severe)**, or ligament
tears, osteoarthritis (moderate or severe )
* * ‫ﺗﻤﺰﻕ ﺍﻷﺭﺑﻄﺔ‬،‫ﺍﻟﺘﻬﺎﺏ ﺍﻟﻤﻔﺎﺻﻞ‬،‫ﺇﻧﺤﺮﺍﻑ ﺍﻟﻌﻤﻮﺩ ﺍﻟﻔﻘﺮﻱ‬,‫ﺍﻟﺪﻳﺴﻚ‬

Pregnant Female Only ‫ﻟﻸﻧﺜﻰ ﺍﻟﺤﺎﻣﻞ ﻓﻘﻂ‬

‫ﺣﻤﻞ ﺣﺎﻟﻲ ﺟﻨﻴﻦ ﻭﺍﺣﺪ‬
Current Single Pregnancy
* *
‫ﺣﻤﻞ ﺣﺎﻟﻲ ﻣﻊ ﻗﻴﺼﺮﻳﺔ ﺳﺎﺑﻘﺔ‬
Current Single Pregnancy with Previous CS Delivery
* *
‫ﺣﻤﻞ ﺣﺎﻟﻲ ﻣﺘﻌﺪﺩ ﺍﻷﺟﻨﺔ‬
Current Multiple Pregnancy
* *
Expected delivery date .. / .. / .... ‫ﺗﺎﺭﻳﺦ ﺍﻟﻮﻻﺩﺓ ﺍﻟﻤﺘﻮﻗﻊ‬
Employee and dependents details that need to be added ‫ﺑﻴﺎﻧﺎﺕ ﺍﻟﻤﻮﻇﻒ ﻭﺃﻓﺮﺍﺩ ﺍﻟﻌﺎﺋﻠﺔ ﺍﻟﻤﺮﺍﺩ ﺇﺿﺎﻓﺘﻬﻢ‬
In case of a yes answer above, please declare the case in the table below ‫ ﺍﻟﺮﺟﺎﺀ ﺫﻛﺮ ﺍﻟﺤﺎﻟﺔ ﻓﻲ ﺍﻟﺠﺪﻭﻝ ﺃﺩﻧﺎﻩ‬،‫ﻓﻲ ﺣﺎﻟﺔ ﺍﻹﺟﺎﺑﺔ ﺑﻨﻌﻢ ﺃﻋﻼﻩ‬
‫ﺇﺳﻢ ﻣﻘﺪﻡ ﺍﻟﺨﺪﻣﺔ‬ ‫ﺍﻟﺤﺎﻟﺔ‬ ‫ﺭﻗﻢ ﺍﻟﺠﻮﺍﻝ‬ ‫ﺍﻟﻄﻮﻝ‬ ‫ﺍﻟﻮﺯﻥ‬ ‫ﺭﻗﻢ ﺍﻟﻬﻮﻳﺔ‬ ‫ﺍﻟﻘﺮﺍﺑﺔ‬ ‫ﺍﻟﺠﻨﺲ‬ ‫ ﺃﻓﺮﺍﺩ ﺍﻟﻌﺎﺋﻠﺔ‬/ ‫ﺍﺳﻢ ﺍﻟﻤﻮﻇﻒ‬ ‫ﻡ‬
2161643941 Child Male / ‫ ﺫﻛﺮ‬Abdulrahman Tahir Khaleequll 1
2
3
4
5
Undertakings : ‫ﺍﻹﻗﺮﺍﺭ ﻭﺍﻟﺘﻔﻮﻳﺾ‬
1- I hereby undertake that all the above information is correct and the acceptance of my ‫ﻭﺍﻟﻤﻌﻠﻮﻣﺎﺕ ﺍﻟﻤﺬﻛﻮﺭﺓ ﺃﻋﻼﻩ ﻛﺎﻣﻠﺔ ﻭﺻﺤﻴﺤﺔ ﻭﺑﻨﺎﺀ ﻋﻠﻴﻪ ﻓﺈﻥ ﻗﺒﻮﻝ ﺍﻟﻄﻠﺐ ﺳﻴﺘﻢ‬: ‫ ﺃﻗﺮ ﺃﻥ ﺍﻟﺒﻴﺎﻧﺎﺕ‬-1
enrollment will be on the basis of such information and that Malath Cooperative Insurance ‫ﻋﻠﻰ ﺃﺳﺎﺱ ﻫﺬﻩ ﺍﻟﺒﻴﺎﻧﺎﺕ ﻭﺃﻥ ﺷﺮﻛﺔ ﻣﻼﺫ ﻟﻠﺘﺄﻣﻴﻦ ﺍﻟﺘﻌﺎﻭﻧﻲ ﻟﻬﺎ ﺍﻟﺤﻖ ﻓﻲ ﺍﻻﺗﺼﺎﻝ ﺑﺎﻟﻤﺴﺘﺸﻔﻴﺎﺕ ﺍﻟﺘﻲ‬
Company has the right to contact the hospital(s) I deal with to collect any ‫ﺃﺗﻌﺎﻣﻞ ﻣﻌﻬﺎ ﻟﺘﺰﻭﻳﺪﻫﺎ ﺑﺄﻱ ﻣﻌﻠﻮﻣﺎﺕ ﻃﺒﻴﺔ ﻗﺪ ﺗﺤﺘﺎﺝ ﺇﻟﻴﻬﺎ ﻟﺘﻘﻴﻴﻢ ﺍﻟﻤﺨﺎﻃﺮ‬
medical information needed to assess the risk(s).

2- I agree that Malath Cooperative Insurance Company has the right to reject the ‫ ﺃﻭﺍﻓﻖ ﻋﻠﻰ ﺃﺣﻘﻴﺔ ﺷﺮﻛﺔ ﻣﻼﺫ ﻟﻠﺘﺄﻣﻴﻦ ﻓﻲ ﺭﻓﺾ ﺍﻟﻤﻄﺎﻟﺒﺔ ﺃﻭ ﺍﻟﺘﻐﻄﻴﺔ ﻛﻠﻴﺎ ﻋﻨﺪ ﻋﺪﻡ ﺍﻹﻓﺼﺎﺡ ﻋﻦ ﻭﺟﻮﺩ ﺃﻱ ﻣﻦ ﺍﻟﺤﺎﻻﺕ‬-2
coverage/claims in full in case of no declaration of any cases prior to the contractual date or ‫ﺍﻟﻤﺬﻛﻮﺭﺓ ﺃﻋﻼﻩ ﺍﻟﺘﻲ ﻧﺸﺄﺕ ﻗﺒﻞ ﺗﺎﺭﻳﺦ ﺍﻟﺘﻌﺎﻗﺪ ﺃﻭ ﻗﺒﻞ ﺗﺴﺠﻴﻞ ﺃﻭ ﺇﺿﺎﻓﺔ ﻋﻀﻮ ﺧﻼﻝ ﻓﺘﺮﺓ ﺳﺮﻳﺎﻥ ﺍﻟﻌﻘﺪ‬
before enrolling or adding a new member during the contract.

3- I hereby confirm reading and understanding all points presented in this form and I agree that ‫ ﺃﻗﺮﺑﺄﻧﻲ ﻗﺪ ﻗﺮﺃﺕ ﻭﻓﻬﻤﺖ ﺟﻤﻴﻊ ﻣﺎ ﺟﺎﺀ ﻓﻲ ﻫﺬﺍ ﺍﻟﻨﻤﻮﺫﺝ ﻛﻤﺎ ﺃﺗﻌﻬﺪ ﺑﺄﻥ ﻋﺪﻡ ﺇﺷﺎﺭﺗﻲ ﺃﻣﺎﻡ ﺃﻱ ﻣﻦ‬-3
not marking any case is understood as “Nothing requires declaration” and I sign on these ‫ﺍﻟﺤﺎﻻﺕ ﺍﻟﻤﺬﻛﻮﺭﺓ ﺃﻋﻼﻩ ﻳﻌﺘﺒﺮ ﺑﻤﺜﺎﺑﺔ ﻧﻔﻲ ﻭﺟﻮﺩ ﻣﺎﻳﺴﺘﺤﻖ ﺍﻹﻓﺼﺎﺡ ﻋﻨﻪ ﻭﻋﻠﻴﻪ ﺃﻭﻗﻊ‬
basis.
4- Failure to fill the weight and height information will result in refusal to cover
the cost of obesity surgery. ‫ ﻋﺪﻡ ﺗﻌﺒﺌﺔ ﺑﻴﺎﻧﺎﺕ ﺍﻟﻄﻮﻝ ﻭﺍﻟﻮﺯﻥ ﺳﻴﺆﺩﻱ ﺇﻟﻰ ﺭﻓﺾ ﺗﻐﻄﻴﺔ ﺗﻜﺎﻟﻴﻒ ﻋﻤﻠﻴﺔ ﺟﺮﺍﺣﺔ ﺍﻟﺴﻤﻨﺔ ﺍﻟﻤﻔﺮﻃﺔ‬-4

Entity's stamp ‫ﺧﺘﻢ ﺟﻬﺔ ﺍﻟﻌﻤﻞ‬ Insured Signature ‫ﺗﻮﻗﻴﻊ ﺍﻟﻤﻮﻇﻒ‬ Date ‫ﺍﻟﺘﺎﺭﻳﺦ‬
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New_Health_Insurance.rdf Page 5 of 39 V.20 13-DEC-2023 01:30 PM

 ‫ﻧﻤﻮﺫﺝ ﺍﻻﻓﺼﺎﺡ ﺍﻟﻄﺒﻲ ﺍﻟﻤﻮﺣﺪ‬
Unified Medical Declaration Form
Product Code: A-MLTH-2-C-08-014
Dear Insured: ‫ﻋﺰﻳﺰﻱ ﺍﻟﻤﺆﻣﻦ ﻟﻪ‬
Please Fill out the form correctly for the purpose of pricing and to ensured that you and your ‫ﻧﺄﻣﻞ ﻗﻴﺎﻣﻚ ﺑﺘﻌﺒﺌﺔ ﻫﺬﺍ ﺍﻟﻨﻤﻮﺫﺝ ﺑﺎﻟﺸﻜﻞ ﺍﻟﺼﺤﻴﺢ ﻟﻐﺮﺽ ﺍﻟﺘﺴﻌﻴﺮ ﻭﻟﻀﻤﺎﻥ ﺣﺼﻮﻟﻚ ﻭﺃﻓﺮﺍﺩ ﺃﺳﺮﺗﻚ ﻋﻠﻰ ﺧﺪﻣﺎﺕ‬
family receive health care services as required according to your unfied policy benefit ‫ﺍﻟﺮﻋﺎﻳﺔ ﺍﻟﺼﺤﻴﺔ ﺑﺎﻟﺸﻜﻞ ﺍﻟﻤﻄﻠﻮﺏ ﺣﺴﺐ ﻣﻨﺎﻓﻊ ﺍﻟﻮﺛﻴﻘﺔ ﺍﻟﻤﻮﺣﺪﺓ‬

Addition ‫ﺇﺿﺎﻓﺔ‬ New ‫ﺟﺪﻳﺪ‬ Type ‫ﻧﻮﻉ ﺍﻟﻄﻠﺐ‬

CR No 7011507360 ‫ﺍﻟﺴﺠﻞ ﺍﻟﺘﺠﺎﺭﻱ‬ Entity Name HADDAJ AL HIJAZ EST ‫ﺃﺳﻢ ﺍﻟﻤﻨﺸﺄﺓ‬
Mobile No 0507579003 ‫ﺭﻗﻢ ﺍﻟﺠﻮﺍﻝ‬ Maimounah Tahir Khaleequllah Walimohammad ‫ﺍﺳﻢ ﺍﻟﻤﻮﻇﻒ‬
ID Number 2 2 0 3 7 2 4 4 2 8 ‫ﺭﻗﻢ ﺍﻟﻬﻮﻳﺔ‬
Gender Female / ‫ﺍﻟﺠﻨﺲ ﺃﻧﺜﻰ‬ Nationality India ‫ ﺍﻟﺠﻨﺴﻴﺔ‬Marital status Married * ‫ﻣﺘﺰﻭﺝ‬ Single R ‫ﺃﻋﺰﺏ‬ ‫ﺍﻟﺤﺎﻟﺔ ﺍﻻﺟﺘﻤﺎﻋﻴﺔ‬
Please declare any of the below cases by marking P under the word Yes ‫ ﻓﻲ ﺍﻟﻤﺮﺑﻊ ﺗﺤﺖ ﻛﻠﻤﺔ ﻧﻌﻢ‬P ‫ﻳﺮﺟﻰ ﺍﻹﻓﺼﺎﺡ ﻋﻦ ﻭﺟﻮﺩ ﺃﻱ ﻣﻦ ﺍﻟﺤﺎﻻﺕ ﺍﺩﻧﺎﻩ ﺑﻮﺿﻊ ﺇﺷﺎﺭﺓ‬
"Below Undeclared Medical Case May Not Be Covered" No / ‫ﻻ‬ Yes / ‫ﻧﻌـﻢ‬ "‫"ﻟﻦ ﺗﺘﻢ ﺍﻟﺘﻐﻄﻴﺔ ﺍﻟﺘﺄﻣﻴﻨﻴﺔ ﻟﻠﺤﺎﻻﺕ ﺃﺩﻧﺎﻩ ﻓﻰ ﺣﺎﻝ ﻋﺪﻡ ﺍﻹﻓﺼﺎﺡ ﻋﻨﻬﺎ‬
Any hospital admission during last 12 months. ‫ ﺷﻬﺮ‬12 ‫ﻫﻞ ﺗﻢ ﺍﻟﺘﻨﻮﻳﻢ ﺑﺎﻟﻤﺴﺘﺸﻔﻰ ﺧﻼﻝ ﺃﺧﺮ‬
"Admission: registering as an admitted patient at the hospital until the following morning "
* * " ‫ ﺗﺴﺠﻴﻞ ﺍﻟﺸﺨﺺ ﺍﻟﻤﺆﻣﻦ ﻟﻪ ﻛﻤﺮﻳﺾ ﻣﻨﻮﻡ ﻓﻲ ﺍﻟﻤﺴﺘﺸﻔﻰ ﺣﺘﻰ ﺻﺒﺎﺡ ﺍﻟﻴﻮﻡ ﺍﻟﺘﺎﻟﻲ‬: ‫" ﺍﻟﺘﻨﻮﻳﻢ‬

Have you been diagnosed with any of the following chronic disease limited ‫ﻫﻞ ﺗﻢ ﺗﺸﺨﻴﺼﻚ ﺑﺄﻯ ﻣﻦ ﺍﻷﻣﺮﺍﺽ ﺍﻟﺘﺎﻟﻴﺔ ﻓﻘﻂ‬
to:Autism, listed Benign Tumor (Breast tumors, fibroid uterus, benign prostatic hyperplasia, ‫ﺃﻭﺭﺍﻡ ﺃﻭ‬,‫ﺗﻀﺨﻢ ﺍﻟﺒﺮﻭﺳﺘﺎﺗﺎ ﺍﻟﺤﻤﻴﺪ‬,‫ ﺃﻭﺭﺍﻡ ﺍﻟﺮﺣﻢ ﺍﻟﻠﻴﻔﻰ‬, ‫ﺍﻻﻭﺭﺍﻡ ﺍﻟﺤﻤﻴﺪﺓ ﺍﻟﺘﺎﻟﻴﺔ )ﺃﻭﺭﺍﻡ ﺍﻟﺜﺪﻯ‬,‫ﺍﻷﻭﺭﺍﻡ ﺍﻟﺴﺮﻃﺎﻧﻴﺔ‬,‫ﺍﻟﺘﻮﺣﺪ‬
thyroid goiter and parathyroid glands, live tumors, colon tumors). Malignant tumors, listed ‫ﺃﻣﺮﺍﺽ ﺍﻟﻘﻠﺐ ﺍﻟﺘﺎﻟﻴﺔ)ﺃﻣﺮﺍﺽ ﺷﺮﺍﻳﻴﻦ ﻭﺻﻤﺎﻣﺎﺕ ﺗﻀﺨﻢ ﺍﻟﻐﺪﺓ ﺍﻟﺪﺭﻗﻴﺔ‬, (‫ﺃﻭﺭﺍﻡ ﺍﻟﻘﻮﻟﻮﻥ‬, ‫ﻭﺃﻭﺭﺍﻡ ﺍﻻﻟﻜﺒﺪ‬,‫ﻭ ﺍﻟﺠﺎﺭ ﺍﻟﺪﺭﻗﻴﺔ‬
Cardiac diseases coronary and valve heart diseases, heart failure, cardiac fibrillation
myocardial infraction, heart clots). Chronic Hepatitis C. Gallstones Sever Kidney failure (stage
* * ‫ﺍﻻﻟﺘﻬﺎﺏ ﺍﻟﻜﺒﺪﻯ ﺍﻟﻔﻴﺮﻭﺳﻰ ﺍﻟﻤﺰﻣﻦ‬.( ‫ﺍﻟﺮﺟﻔﺎﻥ ﺍﻟﻘﻠﺒﻰ ﻭﺟﻠﻄﺎﺕ ﺍﻟﻘﻠﺐ‬, ‫ﻓﺸﻞ ﻋﻀﻠﺔ ﺍﻟﻘﻠﺐ‬, ‫ﺣﺼﻮﺍﺕ ﺍﻟﻤﺮﺍﺭﺓ ﺍﻟﻘﻠﺐ‬, ‫ﺝ ﻭﺳﻰ‬
,‫ ﺍﻟﺘﺮﺷﻴﺢ ﺍﻟﻜﻠﻮﻯ ﺃﻗﻞ ﻣﻦ‬,‫ ﺍﻟﻔﺸﻞ ﺍﻟﻜﻠﻮﻯﺍﻟﺸﺪﻳﺪ )ﺍﻟﻤﺮﺣﻠﺔ ﺍﻟﺨﺎﻣﺴﺔ ﻣﻦ ﺍﻣﺮﺍﺽ ﺍﻟﻜﻠﻰ ﺍﻟﺘﻰ ﺗﺴﺘﺪﻋﻰ ﺍﻟﻐﺴﻴﻞ ﺍﻟﻜﻠﻮﻯ‬15
5 Requiring dialysis, clearance of less tha 15 ml/ minute*). Urinary tract ‫ﻣﺮﺽ‬, ‫ﺩﻗﻴﻘﺔ(ﺣﺼﻮﺍﺕ ﺍﻟﻤﺴﺎﻟﻚ ﺍﻟﺒﻮﻟﻴﺔﺃﻣﺮﺍﺽ ﺍﻟﻤﻨﺎﻋﺔ ﺍﻟﺘﺎﻟﻴﺔ )ﺍﻟﺬﺋﺒﺔ ﺍﻟﺤﻤﺮﺍﺀﻭﺍﻟﺘﻬﺎﺏ ﺍﻟﻤﻔﺎﺻﻞ ﺍﻟﺮﻭﻣﺎﺗﻴﺰﻣﻴﺔﻭ ﺍﻟﺼﺪﻓﻴﺔ‬/‫ﻣﻞ‬
stones, hernias. Autoimmune disease (lupus, rheumatoid arthritis, psoriasis, Crohn's disease, ‫ﺍﻟﺘﻬﺎﺏ ﺍﻟﻘﻮﻟﻮﻥ ﺍﻟﺘﻘﺮﺣﻰ‬, ‫ﻛﺮﻭﻧﺰ‬,
ulcerative colitis,multiple sclerosis, celiac disease) ‫ﺣﺴﺎﺳﻴﺔ ﺍﻟﻘﻤﺢ‬, ‫ﺍﻟﺘﺼﻠﺐ ﺍﻟﻠﻮﻳﺤﻰ‬

Have you been diagnosed with any of the following congenital disorder or
hereditary diseases limited to: Cerebral palsy, Sickle cell disorder, Thalassemia, ‫ﻫﻞ ﺗﻢ ﺗﺸﺨﻴﺼﻚ ﺑﺄﻱ ﻣﻦ ﺍﻷﻣﺮﺍﺽ ﺍﻟﻮﺭﺍﺛﻴﺔ ﺃﻭ ﺍﻟﺘﺸﻮﻫﺎﺕ ﺍﻟﺨﻠﻘﻴﺔ ﺍﻟﺘﺎﻟﻴﺔ ﻓﻘﻂ‬
hemophilia, metabolic diseases, Hydrocephalus, spinal muscle atrophy, genital ‫ ﺿﻤﻮﺭ‬،‫ ﺃﺳﺘﺴﻘﺎﺀ ﺍﻟﺮﺃﺱ‬،‫ ﺃﻣﺮﺍﺽ ﺍﻟﺘﻤﺜﻴﻞ ﺍﻟﻐﺬﺍﺋﻲ‬،‫ ﺍﻟﻬﻴﻤﻮﻓﻴﻠﻴﺎ‬،‫ ﺍﻟﺘﻼﺳﻴﻤﻴﺎ‬،‫ﺍﺿﻄﺮﺍﺏ ﺍﻟﺨﻼﻳﺎ ﺍﻟﻤﻨﺠﻠﻴﺔ‬, ‫ﺍﻟﺸﻠﻞ ﺍﻟﺪﻣﺎﻏﻰ‬
malformations, chromosomal abnormalities. Gaucher's disease, G6PD Deficiency, cystic
fibrosis, hemochromatosis, Wilson disease. Polycystic Kidney Disease.
* * ‫ ﻣﺮﺽ ﺍﻟﺘﻜﺴﺮﺍﻟﻔﻮﻟﻰ‬،‫ ﻣﺮﺽ ﻏﻮﺷﺮ‬،‫ ﺃﻣﺮﺍﺽ ﺍﻟﻜﺮﻭﻣﻮﺳﻮﻣﺎﺕ‬،‫ ﺗﺸﻮﻫﺎﺕ ﺍﻷﻋﻀﺎﺀ ﺍﻟﺘﻨﺎﺳﻠﻴﺔ‬،‫ﺍﻟﻌﻀﻼﺕ ﺍﻟﺸﻮﻛﻲ‬
‫ﺗﻜﻴﺲ‬,‫ﻣﺮﺽ ﻭﻳﻠﺴﻮﻥ‬, (‫ ﻣﺮﺽ ﺗﻜﺪﺱ ﺍﻟﺤﺪﻳﺪ )ﻫﻴﻤﻮﻛﺮﻭﻣﺎﺗﻮﺳﻴﺲ‬،‫( ﺍﻟﺘﻠﻴﻒ ﺍﻟﻜﻴﺴﻲ ﻟﻠﺮﺋﺔ‬G6PD)
‫ﺍﻟﻜﻠﻴﺘﻴﻦ ﺍﻟﺨﻠﻔﻰ ﺍﻟﻮﺭﺍﺋﻰ‬

Have you been diagnosed with any of following eye diseases limited to: ،‫ ﻣﻴﺎﺓ ﺯﺭﻗﺎﺀ‬،‫ ﻣﻴﺎﺓ ﺑﻴﻀﺎﺀ‬:‫ﻫﻞ ﺗﻢ ﺗﺸﺨﻴﺼﻚ ﺑﺄﻱ ﻣﻦ ﺃﻣﺮﺍﺽ ﺍﻟﻌﻴﻦ ﺍﻟﺘﺎﻟﻴﺔ ﻓﻘﻂ‬
Cataract, Glaucoma, Retinal diseases. * * ‫ﺃﻣﺮﺍﺽ ﺍﻟﺸﺒﻜﻴﺔ‬
Have you been diagnosed with any of the following bone diseases limited ‫ ﺍﻹﻧﺰﻻﻕ ﺍﻟﻐﻀﺮﻭﻓﻲ‬:‫ﻫﻞ ﺗﻢ ﺗﺸﺨﻴﺼﻚ ﺑﺄﻱ ﻣﻦ ﺃﻣﺮﺍﺽ ﺍﻟﻌﻈﺎﻡ ﺍﻟﺘﺎﻟﻴﺔ ﻓﻘﻂ‬
to:Vertebral disc prolapse (moderate or severe), Scoliosis (moderate or severe)**, or ligament
tears, osteoarthritis (moderate or severe )
* * ‫ﺗﻤﺰﻕ ﺍﻷﺭﺑﻄﺔ‬،‫ﺍﻟﺘﻬﺎﺏ ﺍﻟﻤﻔﺎﺻﻞ‬،‫ﺇﻧﺤﺮﺍﻑ ﺍﻟﻌﻤﻮﺩ ﺍﻟﻔﻘﺮﻱ‬,‫ﺍﻟﺪﻳﺴﻚ‬

Pregnant Female Only ‫ﻟﻸﻧﺜﻰ ﺍﻟﺤﺎﻣﻞ ﻓﻘﻂ‬

‫ﺣﻤﻞ ﺣﺎﻟﻲ ﺟﻨﻴﻦ ﻭﺍﺣﺪ‬
Current Single Pregnancy
* *
‫ﺣﻤﻞ ﺣﺎﻟﻲ ﻣﻊ ﻗﻴﺼﺮﻳﺔ ﺳﺎﺑﻘﺔ‬
Current Single Pregnancy with Previous CS Delivery
* *
‫ﺣﻤﻞ ﺣﺎﻟﻲ ﻣﺘﻌﺪﺩ ﺍﻷﺟﻨﺔ‬
Current Multiple Pregnancy
* *
Expected delivery date .. / .. / .... ‫ﺗﺎﺭﻳﺦ ﺍﻟﻮﻻﺩﺓ ﺍﻟﻤﺘﻮﻗﻊ‬
Employee and dependents details that need to be added ‫ﺑﻴﺎﻧﺎﺕ ﺍﻟﻤﻮﻇﻒ ﻭﺃﻓﺮﺍﺩ ﺍﻟﻌﺎﺋﻠﺔ ﺍﻟﻤﺮﺍﺩ ﺇﺿﺎﻓﺘﻬﻢ‬
In case of a yes answer above, please declare the case in the table below ‫ ﺍﻟﺮﺟﺎﺀ ﺫﻛﺮ ﺍﻟﺤﺎﻟﺔ ﻓﻲ ﺍﻟﺠﺪﻭﻝ ﺃﺩﻧﺎﻩ‬،‫ﻓﻲ ﺣﺎﻟﺔ ﺍﻹﺟﺎﺑﺔ ﺑﻨﻌﻢ ﺃﻋﻼﻩ‬
‫ﺇﺳﻢ ﻣﻘﺪﻡ ﺍﻟﺨﺪﻣﺔ‬ ‫ﺍﻟﺤﺎﻟﺔ‬ ‫ﺭﻗﻢ ﺍﻟﺠﻮﺍﻝ‬ ‫ﺍﻟﻄﻮﻝ‬ ‫ﺍﻟﻮﺯﻥ‬ ‫ﺭﻗﻢ ﺍﻟﻬﻮﻳﺔ‬ ‫ﺍﻟﻘﺮﺍﺑﺔ‬ ‫ﺍﻟﺠﻨﺲ‬ ‫ ﺃﻓﺮﺍﺩ ﺍﻟﻌﺎﺋﻠﺔ‬/ ‫ﺍﺳﻢ ﺍﻟﻤﻮﻇﻒ‬ ‫ﻡ‬
2203724428 Child Female / ‫ ﺃﻧﺜﻰ‬Maimounah Tahir Khaleequlla 1
2
3
4
5
Undertakings : ‫ﺍﻹﻗﺮﺍﺭ ﻭﺍﻟﺘﻔﻮﻳﺾ‬
1- I hereby undertake that all the above information is correct and the acceptance of my ‫ﻭﺍﻟﻤﻌﻠﻮﻣﺎﺕ ﺍﻟﻤﺬﻛﻮﺭﺓ ﺃﻋﻼﻩ ﻛﺎﻣﻠﺔ ﻭﺻﺤﻴﺤﺔ ﻭﺑﻨﺎﺀ ﻋﻠﻴﻪ ﻓﺈﻥ ﻗﺒﻮﻝ ﺍﻟﻄﻠﺐ ﺳﻴﺘﻢ‬: ‫ ﺃﻗﺮ ﺃﻥ ﺍﻟﺒﻴﺎﻧﺎﺕ‬-1
enrollment will be on the basis of such information and that Malath Cooperative Insurance ‫ﻋﻠﻰ ﺃﺳﺎﺱ ﻫﺬﻩ ﺍﻟﺒﻴﺎﻧﺎﺕ ﻭﺃﻥ ﺷﺮﻛﺔ ﻣﻼﺫ ﻟﻠﺘﺄﻣﻴﻦ ﺍﻟﺘﻌﺎﻭﻧﻲ ﻟﻬﺎ ﺍﻟﺤﻖ ﻓﻲ ﺍﻻﺗﺼﺎﻝ ﺑﺎﻟﻤﺴﺘﺸﻔﻴﺎﺕ ﺍﻟﺘﻲ‬
Company has the right to contact the hospital(s) I deal with to collect any ‫ﺃﺗﻌﺎﻣﻞ ﻣﻌﻬﺎ ﻟﺘﺰﻭﻳﺪﻫﺎ ﺑﺄﻱ ﻣﻌﻠﻮﻣﺎﺕ ﻃﺒﻴﺔ ﻗﺪ ﺗﺤﺘﺎﺝ ﺇﻟﻴﻬﺎ ﻟﺘﻘﻴﻴﻢ ﺍﻟﻤﺨﺎﻃﺮ‬
medical information needed to assess the risk(s).

2- I agree that Malath Cooperative Insurance Company has the right to reject the ‫ ﺃﻭﺍﻓﻖ ﻋﻠﻰ ﺃﺣﻘﻴﺔ ﺷﺮﻛﺔ ﻣﻼﺫ ﻟﻠﺘﺄﻣﻴﻦ ﻓﻲ ﺭﻓﺾ ﺍﻟﻤﻄﺎﻟﺒﺔ ﺃﻭ ﺍﻟﺘﻐﻄﻴﺔ ﻛﻠﻴﺎ ﻋﻨﺪ ﻋﺪﻡ ﺍﻹﻓﺼﺎﺡ ﻋﻦ ﻭﺟﻮﺩ ﺃﻱ ﻣﻦ ﺍﻟﺤﺎﻻﺕ‬-2
coverage/claims in full in case of no declaration of any cases prior to the contractual date or ‫ﺍﻟﻤﺬﻛﻮﺭﺓ ﺃﻋﻼﻩ ﺍﻟﺘﻲ ﻧﺸﺄﺕ ﻗﺒﻞ ﺗﺎﺭﻳﺦ ﺍﻟﺘﻌﺎﻗﺪ ﺃﻭ ﻗﺒﻞ ﺗﺴﺠﻴﻞ ﺃﻭ ﺇﺿﺎﻓﺔ ﻋﻀﻮ ﺧﻼﻝ ﻓﺘﺮﺓ ﺳﺮﻳﺎﻥ ﺍﻟﻌﻘﺪ‬
before enrolling or adding a new member during the contract.

3- I hereby confirm reading and understanding all points presented in this form and I agree that ‫ ﺃﻗﺮﺑﺄﻧﻲ ﻗﺪ ﻗﺮﺃﺕ ﻭﻓﻬﻤﺖ ﺟﻤﻴﻊ ﻣﺎ ﺟﺎﺀ ﻓﻲ ﻫﺬﺍ ﺍﻟﻨﻤﻮﺫﺝ ﻛﻤﺎ ﺃﺗﻌﻬﺪ ﺑﺄﻥ ﻋﺪﻡ ﺇﺷﺎﺭﺗﻲ ﺃﻣﺎﻡ ﺃﻱ ﻣﻦ‬-3
not marking any case is understood as “Nothing requires declaration” and I sign on these ‫ﺍﻟﺤﺎﻻﺕ ﺍﻟﻤﺬﻛﻮﺭﺓ ﺃﻋﻼﻩ ﻳﻌﺘﺒﺮ ﺑﻤﺜﺎﺑﺔ ﻧﻔﻲ ﻭﺟﻮﺩ ﻣﺎﻳﺴﺘﺤﻖ ﺍﻹﻓﺼﺎﺡ ﻋﻨﻪ ﻭﻋﻠﻴﻪ ﺃﻭﻗﻊ‬
basis.
4- Failure to fill the weight and height information will result in refusal to cover
the cost of obesity surgery. ‫ ﻋﺪﻡ ﺗﻌﺒﺌﺔ ﺑﻴﺎﻧﺎﺕ ﺍﻟﻄﻮﻝ ﻭﺍﻟﻮﺯﻥ ﺳﻴﺆﺩﻱ ﺇﻟﻰ ﺭﻓﺾ ﺗﻐﻄﻴﺔ ﺗﻜﺎﻟﻴﻒ ﻋﻤﻠﻴﺔ ﺟﺮﺍﺣﺔ ﺍﻟﺴﻤﻨﺔ ﺍﻟﻤﻔﺮﻃﺔ‬-4

Entity's stamp ‫ﺧﺘﻢ ﺟﻬﺔ ﺍﻟﻌﻤﻞ‬ Insured Signature ‫ﺗﻮﻗﻴﻊ ﺍﻟﻤﻮﻇﻒ‬ Date ‫ﺍﻟﺘﺎﺭﻳﺦ‬
.. / .. / ....

New_Health_Insurance.rdf Page 6 of 39 V.20 13-DEC-2023 01:30 PM

 ‫ﻧﻤﻮﺫﺝ ﺍﻻﻓﺼﺎﺡ ﺍﻟﻄﺒﻲ ﺍﻟﻤﻮﺣﺪ‬
Unified Medical Declaration Form
Product Code: A-MLTH-2-C-08-014
Dear Insured: ‫ﻋﺰﻳﺰﻱ ﺍﻟﻤﺆﻣﻦ ﻟﻪ‬
Please Fill out the form correctly for the purpose of pricing and to ensured that you and your ‫ﻧﺄﻣﻞ ﻗﻴﺎﻣﻚ ﺑﺘﻌﺒﺌﺔ ﻫﺬﺍ ﺍﻟﻨﻤﻮﺫﺝ ﺑﺎﻟﺸﻜﻞ ﺍﻟﺼﺤﻴﺢ ﻟﻐﺮﺽ ﺍﻟﺘﺴﻌﻴﺮ ﻭﻟﻀﻤﺎﻥ ﺣﺼﻮﻟﻚ ﻭﺃﻓﺮﺍﺩ ﺃﺳﺮﺗﻚ ﻋﻠﻰ ﺧﺪﻣﺎﺕ‬
family receive health care services as required according to your unfied policy benefit ‫ﺍﻟﺮﻋﺎﻳﺔ ﺍﻟﺼﺤﻴﺔ ﺑﺎﻟﺸﻜﻞ ﺍﻟﻤﻄﻠﻮﺏ ﺣﺴﺐ ﻣﻨﺎﻓﻊ ﺍﻟﻮﺛﻴﻘﺔ ﺍﻟﻤﻮﺣﺪﺓ‬

Addition ‫ﺇﺿﺎﻓﺔ‬ New ‫ﺟﺪﻳﺪ‬ Type ‫ﻧﻮﻉ ﺍﻟﻄﻠﺐ‬

CR No 7011507360 ‫ﺍﻟﺴﺠﻞ ﺍﻟﺘﺠﺎﺭﻱ‬ Entity Name HADDAJ AL HIJAZ EST ‫ﺃﺳﻢ ﺍﻟﻤﻨﺸﺄﺓ‬
Mobile No 0507579003 ‫ﺭﻗﻢ ﺍﻟﺠﻮﺍﻝ‬ Bashaeer Tahir Khaliqullah Walimohammad ‫ﺍﺳﻢ ﺍﻟﻤﻮﻇﻒ‬
ID Number 2 2 9 7 5 6 4 4 6 6 ‫ﺭﻗﻢ ﺍﻟﻬﻮﻳﺔ‬
Gender Female / ‫ﺍﻟﺠﻨﺲ ﺃﻧﺜﻰ‬ Nationality India ‫ ﺍﻟﺠﻨﺴﻴﺔ‬Marital status Married * ‫ﻣﺘﺰﻭﺝ‬ Single R ‫ﺃﻋﺰﺏ‬ ‫ﺍﻟﺤﺎﻟﺔ ﺍﻻﺟﺘﻤﺎﻋﻴﺔ‬
Please declare any of the below cases by marking P under the word Yes ‫ ﻓﻲ ﺍﻟﻤﺮﺑﻊ ﺗﺤﺖ ﻛﻠﻤﺔ ﻧﻌﻢ‬P ‫ﻳﺮﺟﻰ ﺍﻹﻓﺼﺎﺡ ﻋﻦ ﻭﺟﻮﺩ ﺃﻱ ﻣﻦ ﺍﻟﺤﺎﻻﺕ ﺍﺩﻧﺎﻩ ﺑﻮﺿﻊ ﺇﺷﺎﺭﺓ‬
"Below Undeclared Medical Case May Not Be Covered" No / ‫ﻻ‬ Yes / ‫ﻧﻌـﻢ‬ "‫"ﻟﻦ ﺗﺘﻢ ﺍﻟﺘﻐﻄﻴﺔ ﺍﻟﺘﺄﻣﻴﻨﻴﺔ ﻟﻠﺤﺎﻻﺕ ﺃﺩﻧﺎﻩ ﻓﻰ ﺣﺎﻝ ﻋﺪﻡ ﺍﻹﻓﺼﺎﺡ ﻋﻨﻬﺎ‬
Any hospital admission during last 12 months. ‫ ﺷﻬﺮ‬12 ‫ﻫﻞ ﺗﻢ ﺍﻟﺘﻨﻮﻳﻢ ﺑﺎﻟﻤﺴﺘﺸﻔﻰ ﺧﻼﻝ ﺃﺧﺮ‬
"Admission: registering as an admitted patient at the hospital until the following morning "
* * " ‫ ﺗﺴﺠﻴﻞ ﺍﻟﺸﺨﺺ ﺍﻟﻤﺆﻣﻦ ﻟﻪ ﻛﻤﺮﻳﺾ ﻣﻨﻮﻡ ﻓﻲ ﺍﻟﻤﺴﺘﺸﻔﻰ ﺣﺘﻰ ﺻﺒﺎﺡ ﺍﻟﻴﻮﻡ ﺍﻟﺘﺎﻟﻲ‬: ‫" ﺍﻟﺘﻨﻮﻳﻢ‬

Have you been diagnosed with any of the following chronic disease limited ‫ﻫﻞ ﺗﻢ ﺗﺸﺨﻴﺼﻚ ﺑﺄﻯ ﻣﻦ ﺍﻷﻣﺮﺍﺽ ﺍﻟﺘﺎﻟﻴﺔ ﻓﻘﻂ‬
to:Autism, listed Benign Tumor (Breast tumors, fibroid uterus, benign prostatic hyperplasia, ‫ﺃﻭﺭﺍﻡ ﺃﻭ‬,‫ﺗﻀﺨﻢ ﺍﻟﺒﺮﻭﺳﺘﺎﺗﺎ ﺍﻟﺤﻤﻴﺪ‬,‫ ﺃﻭﺭﺍﻡ ﺍﻟﺮﺣﻢ ﺍﻟﻠﻴﻔﻰ‬, ‫ﺍﻻﻭﺭﺍﻡ ﺍﻟﺤﻤﻴﺪﺓ ﺍﻟﺘﺎﻟﻴﺔ )ﺃﻭﺭﺍﻡ ﺍﻟﺜﺪﻯ‬,‫ﺍﻷﻭﺭﺍﻡ ﺍﻟﺴﺮﻃﺎﻧﻴﺔ‬,‫ﺍﻟﺘﻮﺣﺪ‬
thyroid goiter and parathyroid glands, live tumors, colon tumors). Malignant tumors, listed ‫ﺃﻣﺮﺍﺽ ﺍﻟﻘﻠﺐ ﺍﻟﺘﺎﻟﻴﺔ)ﺃﻣﺮﺍﺽ ﺷﺮﺍﻳﻴﻦ ﻭﺻﻤﺎﻣﺎﺕ ﺗﻀﺨﻢ ﺍﻟﻐﺪﺓ ﺍﻟﺪﺭﻗﻴﺔ‬, (‫ﺃﻭﺭﺍﻡ ﺍﻟﻘﻮﻟﻮﻥ‬, ‫ﻭﺃﻭﺭﺍﻡ ﺍﻻﻟﻜﺒﺪ‬,‫ﻭ ﺍﻟﺠﺎﺭ ﺍﻟﺪﺭﻗﻴﺔ‬
Cardiac diseases coronary and valve heart diseases, heart failure, cardiac fibrillation
myocardial infraction, heart clots). Chronic Hepatitis C. Gallstones Sever Kidney failure (stage
* * ‫ﺍﻻﻟﺘﻬﺎﺏ ﺍﻟﻜﺒﺪﻯ ﺍﻟﻔﻴﺮﻭﺳﻰ ﺍﻟﻤﺰﻣﻦ‬.( ‫ﺍﻟﺮﺟﻔﺎﻥ ﺍﻟﻘﻠﺒﻰ ﻭﺟﻠﻄﺎﺕ ﺍﻟﻘﻠﺐ‬, ‫ﻓﺸﻞ ﻋﻀﻠﺔ ﺍﻟﻘﻠﺐ‬, ‫ﺣﺼﻮﺍﺕ ﺍﻟﻤﺮﺍﺭﺓ ﺍﻟﻘﻠﺐ‬, ‫ﺝ ﻭﺳﻰ‬
,‫ ﺍﻟﺘﺮﺷﻴﺢ ﺍﻟﻜﻠﻮﻯ ﺃﻗﻞ ﻣﻦ‬,‫ ﺍﻟﻔﺸﻞ ﺍﻟﻜﻠﻮﻯﺍﻟﺸﺪﻳﺪ )ﺍﻟﻤﺮﺣﻠﺔ ﺍﻟﺨﺎﻣﺴﺔ ﻣﻦ ﺍﻣﺮﺍﺽ ﺍﻟﻜﻠﻰ ﺍﻟﺘﻰ ﺗﺴﺘﺪﻋﻰ ﺍﻟﻐﺴﻴﻞ ﺍﻟﻜﻠﻮﻯ‬15
5 Requiring dialysis, clearance of less tha 15 ml/ minute*). Urinary tract ‫ﻣﺮﺽ‬, ‫ﺩﻗﻴﻘﺔ(ﺣﺼﻮﺍﺕ ﺍﻟﻤﺴﺎﻟﻚ ﺍﻟﺒﻮﻟﻴﺔﺃﻣﺮﺍﺽ ﺍﻟﻤﻨﺎﻋﺔ ﺍﻟﺘﺎﻟﻴﺔ )ﺍﻟﺬﺋﺒﺔ ﺍﻟﺤﻤﺮﺍﺀﻭﺍﻟﺘﻬﺎﺏ ﺍﻟﻤﻔﺎﺻﻞ ﺍﻟﺮﻭﻣﺎﺗﻴﺰﻣﻴﺔﻭ ﺍﻟﺼﺪﻓﻴﺔ‬/‫ﻣﻞ‬
stones, hernias. Autoimmune disease (lupus, rheumatoid arthritis, psoriasis, Crohn's disease, ‫ﺍﻟﺘﻬﺎﺏ ﺍﻟﻘﻮﻟﻮﻥ ﺍﻟﺘﻘﺮﺣﻰ‬, ‫ﻛﺮﻭﻧﺰ‬,
ulcerative colitis,multiple sclerosis, celiac disease) ‫ﺣﺴﺎﺳﻴﺔ ﺍﻟﻘﻤﺢ‬, ‫ﺍﻟﺘﺼﻠﺐ ﺍﻟﻠﻮﻳﺤﻰ‬

Have you been diagnosed with any of the following congenital disorder or
hereditary diseases limited to: Cerebral palsy, Sickle cell disorder, Thalassemia, ‫ﻫﻞ ﺗﻢ ﺗﺸﺨﻴﺼﻚ ﺑﺄﻱ ﻣﻦ ﺍﻷﻣﺮﺍﺽ ﺍﻟﻮﺭﺍﺛﻴﺔ ﺃﻭ ﺍﻟﺘﺸﻮﻫﺎﺕ ﺍﻟﺨﻠﻘﻴﺔ ﺍﻟﺘﺎﻟﻴﺔ ﻓﻘﻂ‬
hemophilia, metabolic diseases, Hydrocephalus, spinal muscle atrophy, genital ‫ ﺿﻤﻮﺭ‬،‫ ﺃﺳﺘﺴﻘﺎﺀ ﺍﻟﺮﺃﺱ‬،‫ ﺃﻣﺮﺍﺽ ﺍﻟﺘﻤﺜﻴﻞ ﺍﻟﻐﺬﺍﺋﻲ‬،‫ ﺍﻟﻬﻴﻤﻮﻓﻴﻠﻴﺎ‬،‫ ﺍﻟﺘﻼﺳﻴﻤﻴﺎ‬،‫ﺍﺿﻄﺮﺍﺏ ﺍﻟﺨﻼﻳﺎ ﺍﻟﻤﻨﺠﻠﻴﺔ‬, ‫ﺍﻟﺸﻠﻞ ﺍﻟﺪﻣﺎﻏﻰ‬
malformations, chromosomal abnormalities. Gaucher's disease, G6PD Deficiency, cystic
fibrosis, hemochromatosis, Wilson disease. Polycystic Kidney Disease.
* * ‫ ﻣﺮﺽ ﺍﻟﺘﻜﺴﺮﺍﻟﻔﻮﻟﻰ‬،‫ ﻣﺮﺽ ﻏﻮﺷﺮ‬،‫ ﺃﻣﺮﺍﺽ ﺍﻟﻜﺮﻭﻣﻮﺳﻮﻣﺎﺕ‬،‫ ﺗﺸﻮﻫﺎﺕ ﺍﻷﻋﻀﺎﺀ ﺍﻟﺘﻨﺎﺳﻠﻴﺔ‬،‫ﺍﻟﻌﻀﻼﺕ ﺍﻟﺸﻮﻛﻲ‬
‫ﺗﻜﻴﺲ‬,‫ﻣﺮﺽ ﻭﻳﻠﺴﻮﻥ‬, (‫ ﻣﺮﺽ ﺗﻜﺪﺱ ﺍﻟﺤﺪﻳﺪ )ﻫﻴﻤﻮﻛﺮﻭﻣﺎﺗﻮﺳﻴﺲ‬،‫( ﺍﻟﺘﻠﻴﻒ ﺍﻟﻜﻴﺴﻲ ﻟﻠﺮﺋﺔ‬G6PD)
‫ﺍﻟﻜﻠﻴﺘﻴﻦ ﺍﻟﺨﻠﻔﻰ ﺍﻟﻮﺭﺍﺋﻰ‬

Have you been diagnosed with any of following eye diseases limited to: ،‫ ﻣﻴﺎﺓ ﺯﺭﻗﺎﺀ‬،‫ ﻣﻴﺎﺓ ﺑﻴﻀﺎﺀ‬:‫ﻫﻞ ﺗﻢ ﺗﺸﺨﻴﺼﻚ ﺑﺄﻱ ﻣﻦ ﺃﻣﺮﺍﺽ ﺍﻟﻌﻴﻦ ﺍﻟﺘﺎﻟﻴﺔ ﻓﻘﻂ‬
Cataract, Glaucoma, Retinal diseases. * * ‫ﺃﻣﺮﺍﺽ ﺍﻟﺸﺒﻜﻴﺔ‬
Have you been diagnosed with any of the following bone diseases limited ‫ ﺍﻹﻧﺰﻻﻕ ﺍﻟﻐﻀﺮﻭﻓﻲ‬:‫ﻫﻞ ﺗﻢ ﺗﺸﺨﻴﺼﻚ ﺑﺄﻱ ﻣﻦ ﺃﻣﺮﺍﺽ ﺍﻟﻌﻈﺎﻡ ﺍﻟﺘﺎﻟﻴﺔ ﻓﻘﻂ‬
to:Vertebral disc prolapse (moderate or severe), Scoliosis (moderate or severe)**, or ligament
tears, osteoarthritis (moderate or severe )
* * ‫ﺗﻤﺰﻕ ﺍﻷﺭﺑﻄﺔ‬،‫ﺍﻟﺘﻬﺎﺏ ﺍﻟﻤﻔﺎﺻﻞ‬،‫ﺇﻧﺤﺮﺍﻑ ﺍﻟﻌﻤﻮﺩ ﺍﻟﻔﻘﺮﻱ‬,‫ﺍﻟﺪﻳﺴﻚ‬

Pregnant Female Only ‫ﻟﻸﻧﺜﻰ ﺍﻟﺤﺎﻣﻞ ﻓﻘﻂ‬

‫ﺣﻤﻞ ﺣﺎﻟﻲ ﺟﻨﻴﻦ ﻭﺍﺣﺪ‬
Current Single Pregnancy
* *
‫ﺣﻤﻞ ﺣﺎﻟﻲ ﻣﻊ ﻗﻴﺼﺮﻳﺔ ﺳﺎﺑﻘﺔ‬
Current Single Pregnancy with Previous CS Delivery
* *
‫ﺣﻤﻞ ﺣﺎﻟﻲ ﻣﺘﻌﺪﺩ ﺍﻷﺟﻨﺔ‬
Current Multiple Pregnancy
* *
Expected delivery date .. / .. / .... ‫ﺗﺎﺭﻳﺦ ﺍﻟﻮﻻﺩﺓ ﺍﻟﻤﺘﻮﻗﻊ‬
Employee and dependents details that need to be added ‫ﺑﻴﺎﻧﺎﺕ ﺍﻟﻤﻮﻇﻒ ﻭﺃﻓﺮﺍﺩ ﺍﻟﻌﺎﺋﻠﺔ ﺍﻟﻤﺮﺍﺩ ﺇﺿﺎﻓﺘﻬﻢ‬
In case of a yes answer above, please declare the case in the table below ‫ ﺍﻟﺮﺟﺎﺀ ﺫﻛﺮ ﺍﻟﺤﺎﻟﺔ ﻓﻲ ﺍﻟﺠﺪﻭﻝ ﺃﺩﻧﺎﻩ‬،‫ﻓﻲ ﺣﺎﻟﺔ ﺍﻹﺟﺎﺑﺔ ﺑﻨﻌﻢ ﺃﻋﻼﻩ‬
‫ﺇﺳﻢ ﻣﻘﺪﻡ ﺍﻟﺨﺪﻣﺔ‬ ‫ﺍﻟﺤﺎﻟﺔ‬ ‫ﺭﻗﻢ ﺍﻟﺠﻮﺍﻝ‬ ‫ﺍﻟﻄﻮﻝ‬ ‫ﺍﻟﻮﺯﻥ‬ ‫ﺭﻗﻢ ﺍﻟﻬﻮﻳﺔ‬ ‫ﺍﻟﻘﺮﺍﺑﺔ‬ ‫ﺍﻟﺠﻨﺲ‬ ‫ ﺃﻓﺮﺍﺩ ﺍﻟﻌﺎﺋﻠﺔ‬/ ‫ﺍﺳﻢ ﺍﻟﻤﻮﻇﻒ‬ ‫ﻡ‬
2297564466 Child Female / ‫ ﺃﻧﺜﻰ‬Bashaeer Tahir Khaliqullah Wa 1
2
3
4
5
Undertakings : ‫ﺍﻹﻗﺮﺍﺭ ﻭﺍﻟﺘﻔﻮﻳﺾ‬
1- I hereby undertake that all the above information is correct and the acceptance of my ‫ﻭﺍﻟﻤﻌﻠﻮﻣﺎﺕ ﺍﻟﻤﺬﻛﻮﺭﺓ ﺃﻋﻼﻩ ﻛﺎﻣﻠﺔ ﻭﺻﺤﻴﺤﺔ ﻭﺑﻨﺎﺀ ﻋﻠﻴﻪ ﻓﺈﻥ ﻗﺒﻮﻝ ﺍﻟﻄﻠﺐ ﺳﻴﺘﻢ‬: ‫ ﺃﻗﺮ ﺃﻥ ﺍﻟﺒﻴﺎﻧﺎﺕ‬-1
enrollment will be on the basis of such information and that Malath Cooperative Insurance ‫ﻋﻠﻰ ﺃﺳﺎﺱ ﻫﺬﻩ ﺍﻟﺒﻴﺎﻧﺎﺕ ﻭﺃﻥ ﺷﺮﻛﺔ ﻣﻼﺫ ﻟﻠﺘﺄﻣﻴﻦ ﺍﻟﺘﻌﺎﻭﻧﻲ ﻟﻬﺎ ﺍﻟﺤﻖ ﻓﻲ ﺍﻻﺗﺼﺎﻝ ﺑﺎﻟﻤﺴﺘﺸﻔﻴﺎﺕ ﺍﻟﺘﻲ‬
Company has the right to contact the hospital(s) I deal with to collect any ‫ﺃﺗﻌﺎﻣﻞ ﻣﻌﻬﺎ ﻟﺘﺰﻭﻳﺪﻫﺎ ﺑﺄﻱ ﻣﻌﻠﻮﻣﺎﺕ ﻃﺒﻴﺔ ﻗﺪ ﺗﺤﺘﺎﺝ ﺇﻟﻴﻬﺎ ﻟﺘﻘﻴﻴﻢ ﺍﻟﻤﺨﺎﻃﺮ‬
medical information needed to assess the risk(s).

2- I agree that Malath Cooperative Insurance Company has the right to reject the ‫ ﺃﻭﺍﻓﻖ ﻋﻠﻰ ﺃﺣﻘﻴﺔ ﺷﺮﻛﺔ ﻣﻼﺫ ﻟﻠﺘﺄﻣﻴﻦ ﻓﻲ ﺭﻓﺾ ﺍﻟﻤﻄﺎﻟﺒﺔ ﺃﻭ ﺍﻟﺘﻐﻄﻴﺔ ﻛﻠﻴﺎ ﻋﻨﺪ ﻋﺪﻡ ﺍﻹﻓﺼﺎﺡ ﻋﻦ ﻭﺟﻮﺩ ﺃﻱ ﻣﻦ ﺍﻟﺤﺎﻻﺕ‬-2
coverage/claims in full in case of no declaration of any cases prior to the contractual date or ‫ﺍﻟﻤﺬﻛﻮﺭﺓ ﺃﻋﻼﻩ ﺍﻟﺘﻲ ﻧﺸﺄﺕ ﻗﺒﻞ ﺗﺎﺭﻳﺦ ﺍﻟﺘﻌﺎﻗﺪ ﺃﻭ ﻗﺒﻞ ﺗﺴﺠﻴﻞ ﺃﻭ ﺇﺿﺎﻓﺔ ﻋﻀﻮ ﺧﻼﻝ ﻓﺘﺮﺓ ﺳﺮﻳﺎﻥ ﺍﻟﻌﻘﺪ‬
before enrolling or adding a new member during the contract.

3- I hereby confirm reading and understanding all points presented in this form and I agree that ‫ ﺃﻗﺮﺑﺄﻧﻲ ﻗﺪ ﻗﺮﺃﺕ ﻭﻓﻬﻤﺖ ﺟﻤﻴﻊ ﻣﺎ ﺟﺎﺀ ﻓﻲ ﻫﺬﺍ ﺍﻟﻨﻤﻮﺫﺝ ﻛﻤﺎ ﺃﺗﻌﻬﺪ ﺑﺄﻥ ﻋﺪﻡ ﺇﺷﺎﺭﺗﻲ ﺃﻣﺎﻡ ﺃﻱ ﻣﻦ‬-3
not marking any case is understood as “Nothing requires declaration” and I sign on these ‫ﺍﻟﺤﺎﻻﺕ ﺍﻟﻤﺬﻛﻮﺭﺓ ﺃﻋﻼﻩ ﻳﻌﺘﺒﺮ ﺑﻤﺜﺎﺑﺔ ﻧﻔﻲ ﻭﺟﻮﺩ ﻣﺎﻳﺴﺘﺤﻖ ﺍﻹﻓﺼﺎﺡ ﻋﻨﻪ ﻭﻋﻠﻴﻪ ﺃﻭﻗﻊ‬
basis.
4- Failure to fill the weight and height information will result in refusal to cover
the cost of obesity surgery. ‫ ﻋﺪﻡ ﺗﻌﺒﺌﺔ ﺑﻴﺎﻧﺎﺕ ﺍﻟﻄﻮﻝ ﻭﺍﻟﻮﺯﻥ ﺳﻴﺆﺩﻱ ﺇﻟﻰ ﺭﻓﺾ ﺗﻐﻄﻴﺔ ﺗﻜﺎﻟﻴﻒ ﻋﻤﻠﻴﺔ ﺟﺮﺍﺣﺔ ﺍﻟﺴﻤﻨﺔ ﺍﻟﻤﻔﺮﻃﺔ‬-4

Entity's stamp ‫ﺧﺘﻢ ﺟﻬﺔ ﺍﻟﻌﻤﻞ‬ Insured Signature ‫ﺗﻮﻗﻴﻊ ﺍﻟﻤﻮﻇﻒ‬ Date ‫ﺍﻟﺘﺎﺭﻳﺦ‬
.. / .. / ....

New_Health_Insurance.rdf Page 7 of 39 V.20 13-DEC-2023 01:30 PM

 ‫ﻧﻤﻮﺫﺝ ﺍﻻﻓﺼﺎﺡ ﺍﻟﻄﺒﻲ ﺍﻟﻤﻮﺣﺪ‬
Unified Medical Declaration Form
Product Code: A-MLTH-2-C-08-014
Dear Insured: ‫ﻋﺰﻳﺰﻱ ﺍﻟﻤﺆﻣﻦ ﻟﻪ‬
Please Fill out the form correctly for the purpose of pricing and to ensured that you and your ‫ﻧﺄﻣﻞ ﻗﻴﺎﻣﻚ ﺑﺘﻌﺒﺌﺔ ﻫﺬﺍ ﺍﻟﻨﻤﻮﺫﺝ ﺑﺎﻟﺸﻜﻞ ﺍﻟﺼﺤﻴﺢ ﻟﻐﺮﺽ ﺍﻟﺘﺴﻌﻴﺮ ﻭﻟﻀﻤﺎﻥ ﺣﺼﻮﻟﻚ ﻭﺃﻓﺮﺍﺩ ﺃﺳﺮﺗﻚ ﻋﻠﻰ ﺧﺪﻣﺎﺕ‬
family receive health care services as required according to your unfied policy benefit ‫ﺍﻟﺮﻋﺎﻳﺔ ﺍﻟﺼﺤﻴﺔ ﺑﺎﻟﺸﻜﻞ ﺍﻟﻤﻄﻠﻮﺏ ﺣﺴﺐ ﻣﻨﺎﻓﻊ ﺍﻟﻮﺛﻴﻘﺔ ﺍﻟﻤﻮﺣﺪﺓ‬

Addition ‫ﺇﺿﺎﻓﺔ‬ New ‫ﺟﺪﻳﺪ‬ Type ‫ﻧﻮﻉ ﺍﻟﻄﻠﺐ‬

CR No 7011507360 ‫ﺍﻟﺴﺠﻞ ﺍﻟﺘﺠﺎﺭﻱ‬ Entity Name HADDAJ AL HIJAZ EST ‫ﺃﺳﻢ ﺍﻟﻤﻨﺸﺄﺓ‬
Mobile No 0507579003 ‫ﺭﻗﻢ ﺍﻟﺠﻮﺍﻝ‬ Elaf Tahir Khaliqullah Walimohammad ‫ﺍﺳﻢ ﺍﻟﻤﻮﻇﻒ‬
ID Number 2 3 7 5 7 3 5 1 1 1 ‫ﺭﻗﻢ ﺍﻟﻬﻮﻳﺔ‬
Gender Female / ‫ﺍﻟﺠﻨﺲ ﺃﻧﺜﻰ‬ Nationality India ‫ ﺍﻟﺠﻨﺴﻴﺔ‬Marital status Married * ‫ﻣﺘﺰﻭﺝ‬ Single R ‫ﺃﻋﺰﺏ‬ ‫ﺍﻟﺤﺎﻟﺔ ﺍﻻﺟﺘﻤﺎﻋﻴﺔ‬
Please declare any of the below cases by marking P under the word Yes ‫ ﻓﻲ ﺍﻟﻤﺮﺑﻊ ﺗﺤﺖ ﻛﻠﻤﺔ ﻧﻌﻢ‬P ‫ﻳﺮﺟﻰ ﺍﻹﻓﺼﺎﺡ ﻋﻦ ﻭﺟﻮﺩ ﺃﻱ ﻣﻦ ﺍﻟﺤﺎﻻﺕ ﺍﺩﻧﺎﻩ ﺑﻮﺿﻊ ﺇﺷﺎﺭﺓ‬
"Below Undeclared Medical Case May Not Be Covered" No / ‫ﻻ‬ Yes / ‫ﻧﻌـﻢ‬ "‫"ﻟﻦ ﺗﺘﻢ ﺍﻟﺘﻐﻄﻴﺔ ﺍﻟﺘﺄﻣﻴﻨﻴﺔ ﻟﻠﺤﺎﻻﺕ ﺃﺩﻧﺎﻩ ﻓﻰ ﺣﺎﻝ ﻋﺪﻡ ﺍﻹﻓﺼﺎﺡ ﻋﻨﻬﺎ‬
Any hospital admission during last 12 months. ‫ ﺷﻬﺮ‬12 ‫ﻫﻞ ﺗﻢ ﺍﻟﺘﻨﻮﻳﻢ ﺑﺎﻟﻤﺴﺘﺸﻔﻰ ﺧﻼﻝ ﺃﺧﺮ‬
"Admission: registering as an admitted patient at the hospital until the following morning "
* * " ‫ ﺗﺴﺠﻴﻞ ﺍﻟﺸﺨﺺ ﺍﻟﻤﺆﻣﻦ ﻟﻪ ﻛﻤﺮﻳﺾ ﻣﻨﻮﻡ ﻓﻲ ﺍﻟﻤﺴﺘﺸﻔﻰ ﺣﺘﻰ ﺻﺒﺎﺡ ﺍﻟﻴﻮﻡ ﺍﻟﺘﺎﻟﻲ‬: ‫" ﺍﻟﺘﻨﻮﻳﻢ‬

Have you been diagnosed with any of the following chronic disease limited ‫ﻫﻞ ﺗﻢ ﺗﺸﺨﻴﺼﻚ ﺑﺄﻯ ﻣﻦ ﺍﻷﻣﺮﺍﺽ ﺍﻟﺘﺎﻟﻴﺔ ﻓﻘﻂ‬
to:Autism, listed Benign Tumor (Breast tumors, fibroid uterus, benign prostatic hyperplasia, ‫ﺃﻭﺭﺍﻡ ﺃﻭ‬,‫ﺗﻀﺨﻢ ﺍﻟﺒﺮﻭﺳﺘﺎﺗﺎ ﺍﻟﺤﻤﻴﺪ‬,‫ ﺃﻭﺭﺍﻡ ﺍﻟﺮﺣﻢ ﺍﻟﻠﻴﻔﻰ‬, ‫ﺍﻻﻭﺭﺍﻡ ﺍﻟﺤﻤﻴﺪﺓ ﺍﻟﺘﺎﻟﻴﺔ )ﺃﻭﺭﺍﻡ ﺍﻟﺜﺪﻯ‬,‫ﺍﻷﻭﺭﺍﻡ ﺍﻟﺴﺮﻃﺎﻧﻴﺔ‬,‫ﺍﻟﺘﻮﺣﺪ‬
thyroid goiter and parathyroid glands, live tumors, colon tumors). Malignant tumors, listed ‫ﺃﻣﺮﺍﺽ ﺍﻟﻘﻠﺐ ﺍﻟﺘﺎﻟﻴﺔ)ﺃﻣﺮﺍﺽ ﺷﺮﺍﻳﻴﻦ ﻭﺻﻤﺎﻣﺎﺕ ﺗﻀﺨﻢ ﺍﻟﻐﺪﺓ ﺍﻟﺪﺭﻗﻴﺔ‬, (‫ﺃﻭﺭﺍﻡ ﺍﻟﻘﻮﻟﻮﻥ‬, ‫ﻭﺃﻭﺭﺍﻡ ﺍﻻﻟﻜﺒﺪ‬,‫ﻭ ﺍﻟﺠﺎﺭ ﺍﻟﺪﺭﻗﻴﺔ‬
Cardiac diseases coronary and valve heart diseases, heart failure, cardiac fibrillation
myocardial infraction, heart clots). Chronic Hepatitis C. Gallstones Sever Kidney failure (stage
* * ‫ﺍﻻﻟﺘﻬﺎﺏ ﺍﻟﻜﺒﺪﻯ ﺍﻟﻔﻴﺮﻭﺳﻰ ﺍﻟﻤﺰﻣﻦ‬.( ‫ﺍﻟﺮﺟﻔﺎﻥ ﺍﻟﻘﻠﺒﻰ ﻭﺟﻠﻄﺎﺕ ﺍﻟﻘﻠﺐ‬, ‫ﻓﺸﻞ ﻋﻀﻠﺔ ﺍﻟﻘﻠﺐ‬, ‫ﺣﺼﻮﺍﺕ ﺍﻟﻤﺮﺍﺭﺓ ﺍﻟﻘﻠﺐ‬, ‫ﺝ ﻭﺳﻰ‬
,‫ ﺍﻟﺘﺮﺷﻴﺢ ﺍﻟﻜﻠﻮﻯ ﺃﻗﻞ ﻣﻦ‬,‫ ﺍﻟﻔﺸﻞ ﺍﻟﻜﻠﻮﻯﺍﻟﺸﺪﻳﺪ )ﺍﻟﻤﺮﺣﻠﺔ ﺍﻟﺨﺎﻣﺴﺔ ﻣﻦ ﺍﻣﺮﺍﺽ ﺍﻟﻜﻠﻰ ﺍﻟﺘﻰ ﺗﺴﺘﺪﻋﻰ ﺍﻟﻐﺴﻴﻞ ﺍﻟﻜﻠﻮﻯ‬15
5 Requiring dialysis, clearance of less tha 15 ml/ minute*). Urinary tract ‫ﻣﺮﺽ‬, ‫ﺩﻗﻴﻘﺔ(ﺣﺼﻮﺍﺕ ﺍﻟﻤﺴﺎﻟﻚ ﺍﻟﺒﻮﻟﻴﺔﺃﻣﺮﺍﺽ ﺍﻟﻤﻨﺎﻋﺔ ﺍﻟﺘﺎﻟﻴﺔ )ﺍﻟﺬﺋﺒﺔ ﺍﻟﺤﻤﺮﺍﺀﻭﺍﻟﺘﻬﺎﺏ ﺍﻟﻤﻔﺎﺻﻞ ﺍﻟﺮﻭﻣﺎﺗﻴﺰﻣﻴﺔﻭ ﺍﻟﺼﺪﻓﻴﺔ‬/‫ﻣﻞ‬
stones, hernias. Autoimmune disease (lupus, rheumatoid arthritis, psoriasis, Crohn's disease, ‫ﺍﻟﺘﻬﺎﺏ ﺍﻟﻘﻮﻟﻮﻥ ﺍﻟﺘﻘﺮﺣﻰ‬, ‫ﻛﺮﻭﻧﺰ‬,
ulcerative colitis,multiple sclerosis, celiac disease) ‫ﺣﺴﺎﺳﻴﺔ ﺍﻟﻘﻤﺢ‬, ‫ﺍﻟﺘﺼﻠﺐ ﺍﻟﻠﻮﻳﺤﻰ‬

Have you been diagnosed with any of the following congenital disorder or
hereditary diseases limited to: Cerebral palsy, Sickle cell disorder, Thalassemia, ‫ﻫﻞ ﺗﻢ ﺗﺸﺨﻴﺼﻚ ﺑﺄﻱ ﻣﻦ ﺍﻷﻣﺮﺍﺽ ﺍﻟﻮﺭﺍﺛﻴﺔ ﺃﻭ ﺍﻟﺘﺸﻮﻫﺎﺕ ﺍﻟﺨﻠﻘﻴﺔ ﺍﻟﺘﺎﻟﻴﺔ ﻓﻘﻂ‬
hemophilia, metabolic diseases, Hydrocephalus, spinal muscle atrophy, genital ‫ ﺿﻤﻮﺭ‬،‫ ﺃﺳﺘﺴﻘﺎﺀ ﺍﻟﺮﺃﺱ‬،‫ ﺃﻣﺮﺍﺽ ﺍﻟﺘﻤﺜﻴﻞ ﺍﻟﻐﺬﺍﺋﻲ‬،‫ ﺍﻟﻬﻴﻤﻮﻓﻴﻠﻴﺎ‬،‫ ﺍﻟﺘﻼﺳﻴﻤﻴﺎ‬،‫ﺍﺿﻄﺮﺍﺏ ﺍﻟﺨﻼﻳﺎ ﺍﻟﻤﻨﺠﻠﻴﺔ‬, ‫ﺍﻟﺸﻠﻞ ﺍﻟﺪﻣﺎﻏﻰ‬
malformations, chromosomal abnormalities. Gaucher's disease, G6PD Deficiency, cystic
fibrosis, hemochromatosis, Wilson disease. Polycystic Kidney Disease.
* * ‫ ﻣﺮﺽ ﺍﻟﺘﻜﺴﺮﺍﻟﻔﻮﻟﻰ‬،‫ ﻣﺮﺽ ﻏﻮﺷﺮ‬،‫ ﺃﻣﺮﺍﺽ ﺍﻟﻜﺮﻭﻣﻮﺳﻮﻣﺎﺕ‬،‫ ﺗﺸﻮﻫﺎﺕ ﺍﻷﻋﻀﺎﺀ ﺍﻟﺘﻨﺎﺳﻠﻴﺔ‬،‫ﺍﻟﻌﻀﻼﺕ ﺍﻟﺸﻮﻛﻲ‬
‫ﺗﻜﻴﺲ‬,‫ﻣﺮﺽ ﻭﻳﻠﺴﻮﻥ‬, (‫ ﻣﺮﺽ ﺗﻜﺪﺱ ﺍﻟﺤﺪﻳﺪ )ﻫﻴﻤﻮﻛﺮﻭﻣﺎﺗﻮﺳﻴﺲ‬،‫( ﺍﻟﺘﻠﻴﻒ ﺍﻟﻜﻴﺴﻲ ﻟﻠﺮﺋﺔ‬G6PD)
‫ﺍﻟﻜﻠﻴﺘﻴﻦ ﺍﻟﺨﻠﻔﻰ ﺍﻟﻮﺭﺍﺋﻰ‬

Have you been diagnosed with any of following eye diseases limited to: ،‫ ﻣﻴﺎﺓ ﺯﺭﻗﺎﺀ‬،‫ ﻣﻴﺎﺓ ﺑﻴﻀﺎﺀ‬:‫ﻫﻞ ﺗﻢ ﺗﺸﺨﻴﺼﻚ ﺑﺄﻱ ﻣﻦ ﺃﻣﺮﺍﺽ ﺍﻟﻌﻴﻦ ﺍﻟﺘﺎﻟﻴﺔ ﻓﻘﻂ‬
Cataract, Glaucoma, Retinal diseases. * * ‫ﺃﻣﺮﺍﺽ ﺍﻟﺸﺒﻜﻴﺔ‬
Have you been diagnosed with any of the following bone diseases limited ‫ ﺍﻹﻧﺰﻻﻕ ﺍﻟﻐﻀﺮﻭﻓﻲ‬:‫ﻫﻞ ﺗﻢ ﺗﺸﺨﻴﺼﻚ ﺑﺄﻱ ﻣﻦ ﺃﻣﺮﺍﺽ ﺍﻟﻌﻈﺎﻡ ﺍﻟﺘﺎﻟﻴﺔ ﻓﻘﻂ‬
to:Vertebral disc prolapse (moderate or severe), Scoliosis (moderate or severe)**, or ligament
tears, osteoarthritis (moderate or severe )
* * ‫ﺗﻤﺰﻕ ﺍﻷﺭﺑﻄﺔ‬،‫ﺍﻟﺘﻬﺎﺏ ﺍﻟﻤﻔﺎﺻﻞ‬،‫ﺇﻧﺤﺮﺍﻑ ﺍﻟﻌﻤﻮﺩ ﺍﻟﻔﻘﺮﻱ‬,‫ﺍﻟﺪﻳﺴﻚ‬

Pregnant Female Only ‫ﻟﻸﻧﺜﻰ ﺍﻟﺤﺎﻣﻞ ﻓﻘﻂ‬

‫ﺣﻤﻞ ﺣﺎﻟﻲ ﺟﻨﻴﻦ ﻭﺍﺣﺪ‬
Current Single Pregnancy
* *
‫ﺣﻤﻞ ﺣﺎﻟﻲ ﻣﻊ ﻗﻴﺼﺮﻳﺔ ﺳﺎﺑﻘﺔ‬
Current Single Pregnancy with Previous CS Delivery
* *
‫ﺣﻤﻞ ﺣﺎﻟﻲ ﻣﺘﻌﺪﺩ ﺍﻷﺟﻨﺔ‬
Current Multiple Pregnancy
* *
Expected delivery date .. / .. / .... ‫ﺗﺎﺭﻳﺦ ﺍﻟﻮﻻﺩﺓ ﺍﻟﻤﺘﻮﻗﻊ‬
Employee and dependents details that need to be added ‫ﺑﻴﺎﻧﺎﺕ ﺍﻟﻤﻮﻇﻒ ﻭﺃﻓﺮﺍﺩ ﺍﻟﻌﺎﺋﻠﺔ ﺍﻟﻤﺮﺍﺩ ﺇﺿﺎﻓﺘﻬﻢ‬
In case of a yes answer above, please declare the case in the table below ‫ ﺍﻟﺮﺟﺎﺀ ﺫﻛﺮ ﺍﻟﺤﺎﻟﺔ ﻓﻲ ﺍﻟﺠﺪﻭﻝ ﺃﺩﻧﺎﻩ‬،‫ﻓﻲ ﺣﺎﻟﺔ ﺍﻹﺟﺎﺑﺔ ﺑﻨﻌﻢ ﺃﻋﻼﻩ‬
‫ﺇﺳﻢ ﻣﻘﺪﻡ ﺍﻟﺨﺪﻣﺔ‬ ‫ﺍﻟﺤﺎﻟﺔ‬ ‫ﺭﻗﻢ ﺍﻟﺠﻮﺍﻝ‬ ‫ﺍﻟﻄﻮﻝ‬ ‫ﺍﻟﻮﺯﻥ‬ ‫ﺭﻗﻢ ﺍﻟﻬﻮﻳﺔ‬ ‫ﺍﻟﻘﺮﺍﺑﺔ‬ ‫ﺍﻟﺠﻨﺲ‬ ‫ ﺃﻓﺮﺍﺩ ﺍﻟﻌﺎﺋﻠﺔ‬/ ‫ﺍﺳﻢ ﺍﻟﻤﻮﻇﻒ‬ ‫ﻡ‬
2375735111 Child Female / ‫ ﺃﻧﺜﻰ‬Elaf Tahir Khaliqullah Walimo 1
2
3
4
5
Undertakings : ‫ﺍﻹﻗﺮﺍﺭ ﻭﺍﻟﺘﻔﻮﻳﺾ‬
1- I hereby undertake that all the above information is correct and the acceptance of my ‫ﻭﺍﻟﻤﻌﻠﻮﻣﺎﺕ ﺍﻟﻤﺬﻛﻮﺭﺓ ﺃﻋﻼﻩ ﻛﺎﻣﻠﺔ ﻭﺻﺤﻴﺤﺔ ﻭﺑﻨﺎﺀ ﻋﻠﻴﻪ ﻓﺈﻥ ﻗﺒﻮﻝ ﺍﻟﻄﻠﺐ ﺳﻴﺘﻢ‬: ‫ ﺃﻗﺮ ﺃﻥ ﺍﻟﺒﻴﺎﻧﺎﺕ‬-1
enrollment will be on the basis of such information and that Malath Cooperative Insurance ‫ﻋﻠﻰ ﺃﺳﺎﺱ ﻫﺬﻩ ﺍﻟﺒﻴﺎﻧﺎﺕ ﻭﺃﻥ ﺷﺮﻛﺔ ﻣﻼﺫ ﻟﻠﺘﺄﻣﻴﻦ ﺍﻟﺘﻌﺎﻭﻧﻲ ﻟﻬﺎ ﺍﻟﺤﻖ ﻓﻲ ﺍﻻﺗﺼﺎﻝ ﺑﺎﻟﻤﺴﺘﺸﻔﻴﺎﺕ ﺍﻟﺘﻲ‬
Company has the right to contact the hospital(s) I deal with to collect any ‫ﺃﺗﻌﺎﻣﻞ ﻣﻌﻬﺎ ﻟﺘﺰﻭﻳﺪﻫﺎ ﺑﺄﻱ ﻣﻌﻠﻮﻣﺎﺕ ﻃﺒﻴﺔ ﻗﺪ ﺗﺤﺘﺎﺝ ﺇﻟﻴﻬﺎ ﻟﺘﻘﻴﻴﻢ ﺍﻟﻤﺨﺎﻃﺮ‬
medical information needed to assess the risk(s).

2- I agree that Malath Cooperative Insurance Company has the right to reject the ‫ ﺃﻭﺍﻓﻖ ﻋﻠﻰ ﺃﺣﻘﻴﺔ ﺷﺮﻛﺔ ﻣﻼﺫ ﻟﻠﺘﺄﻣﻴﻦ ﻓﻲ ﺭﻓﺾ ﺍﻟﻤﻄﺎﻟﺒﺔ ﺃﻭ ﺍﻟﺘﻐﻄﻴﺔ ﻛﻠﻴﺎ ﻋﻨﺪ ﻋﺪﻡ ﺍﻹﻓﺼﺎﺡ ﻋﻦ ﻭﺟﻮﺩ ﺃﻱ ﻣﻦ ﺍﻟﺤﺎﻻﺕ‬-2
coverage/claims in full in case of no declaration of any cases prior to the contractual date or ‫ﺍﻟﻤﺬﻛﻮﺭﺓ ﺃﻋﻼﻩ ﺍﻟﺘﻲ ﻧﺸﺄﺕ ﻗﺒﻞ ﺗﺎﺭﻳﺦ ﺍﻟﺘﻌﺎﻗﺪ ﺃﻭ ﻗﺒﻞ ﺗﺴﺠﻴﻞ ﺃﻭ ﺇﺿﺎﻓﺔ ﻋﻀﻮ ﺧﻼﻝ ﻓﺘﺮﺓ ﺳﺮﻳﺎﻥ ﺍﻟﻌﻘﺪ‬
before enrolling or adding a new member during the contract.

3- I hereby confirm reading and understanding all points presented in this form and I agree that ‫ ﺃﻗﺮﺑﺄﻧﻲ ﻗﺪ ﻗﺮﺃﺕ ﻭﻓﻬﻤﺖ ﺟﻤﻴﻊ ﻣﺎ ﺟﺎﺀ ﻓﻲ ﻫﺬﺍ ﺍﻟﻨﻤﻮﺫﺝ ﻛﻤﺎ ﺃﺗﻌﻬﺪ ﺑﺄﻥ ﻋﺪﻡ ﺇﺷﺎﺭﺗﻲ ﺃﻣﺎﻡ ﺃﻱ ﻣﻦ‬-3
not marking any case is understood as “Nothing requires declaration” and I sign on these ‫ﺍﻟﺤﺎﻻﺕ ﺍﻟﻤﺬﻛﻮﺭﺓ ﺃﻋﻼﻩ ﻳﻌﺘﺒﺮ ﺑﻤﺜﺎﺑﺔ ﻧﻔﻲ ﻭﺟﻮﺩ ﻣﺎﻳﺴﺘﺤﻖ ﺍﻹﻓﺼﺎﺡ ﻋﻨﻪ ﻭﻋﻠﻴﻪ ﺃﻭﻗﻊ‬
basis.
4- Failure to fill the weight and height information will result in refusal to cover
the cost of obesity surgery. ‫ ﻋﺪﻡ ﺗﻌﺒﺌﺔ ﺑﻴﺎﻧﺎﺕ ﺍﻟﻄﻮﻝ ﻭﺍﻟﻮﺯﻥ ﺳﻴﺆﺩﻱ ﺇﻟﻰ ﺭﻓﺾ ﺗﻐﻄﻴﺔ ﺗﻜﺎﻟﻴﻒ ﻋﻤﻠﻴﺔ ﺟﺮﺍﺣﺔ ﺍﻟﺴﻤﻨﺔ ﺍﻟﻤﻔﺮﻃﺔ‬-4

Entity's stamp ‫ﺧﺘﻢ ﺟﻬﺔ ﺍﻟﻌﻤﻞ‬ Insured Signature ‫ﺗﻮﻗﻴﻊ ﺍﻟﻤﻮﻇﻒ‬ Date ‫ﺍﻟﺘﺎﺭﻳﺦ‬
.. / .. / ....

New_Health_Insurance.rdf Page 8 of 39 V.20 13-DEC-2023 01:30 PM

 ‫ﻧﻤﻮﺫﺝ ﺍﻻﻓﺼﺎﺡ ﺍﻟﻄﺒﻲ ﺍﻟﻤﻮﺣﺪ‬
Unified Medical Declaration Form
Product Code: A-MLTH-2-C-08-014
Dear Insured: ‫ﻋﺰﻳﺰﻱ ﺍﻟﻤﺆﻣﻦ ﻟﻪ‬
Please Fill out the form correctly for the purpose of pricing and to ensured that you and your ‫ﻧﺄﻣﻞ ﻗﻴﺎﻣﻚ ﺑﺘﻌﺒﺌﺔ ﻫﺬﺍ ﺍﻟﻨﻤﻮﺫﺝ ﺑﺎﻟﺸﻜﻞ ﺍﻟﺼﺤﻴﺢ ﻟﻐﺮﺽ ﺍﻟﺘﺴﻌﻴﺮ ﻭﻟﻀﻤﺎﻥ ﺣﺼﻮﻟﻚ ﻭﺃﻓﺮﺍﺩ ﺃﺳﺮﺗﻚ ﻋﻠﻰ ﺧﺪﻣﺎﺕ‬
family receive health care services as required according to your unfied policy benefit ‫ﺍﻟﺮﻋﺎﻳﺔ ﺍﻟﺼﺤﻴﺔ ﺑﺎﻟﺸﻜﻞ ﺍﻟﻤﻄﻠﻮﺏ ﺣﺴﺐ ﻣﻨﺎﻓﻊ ﺍﻟﻮﺛﻴﻘﺔ ﺍﻟﻤﻮﺣﺪﺓ‬

Addition ‫ﺇﺿﺎﻓﺔ‬ New ‫ﺟﺪﻳﺪ‬ Type ‫ﻧﻮﻉ ﺍﻟﻄﻠﺐ‬

CR No 7011507360 ‫ﺍﻟﺴﺠﻞ ﺍﻟﺘﺠﺎﺭﻱ‬ Entity Name HADDAJ AL HIJAZ EST ‫ﺃﺳﻢ ﺍﻟﻤﻨﺸﺄﺓ‬
Mobile No 0507579003 ‫ﺭﻗﻢ ﺍﻟﺠﻮﺍﻝ‬ Saad Tahir Khaliqullah Walimohammad ‫ﺍﺳﻢ ﺍﻟﻤﻮﻇﻒ‬
ID Number 2 4 2 3 8 9 9 8 0 2 ‫ﺭﻗﻢ ﺍﻟﻬﻮﻳﺔ‬
Male / ‫ﺫﻛﺮ‬ India
Gender ‫ ﺍﻟﺠﻨﺲ‬Nationality ‫ ﺍﻟﺠﻨﺴﻴﺔ‬Marital status Married * ‫ﻣﺘﺰﻭﺝ‬ Single R ‫ﺃﻋﺰﺏ‬ ‫ﺍﻟﺤﺎﻟﺔ ﺍﻻﺟﺘﻤﺎﻋﻴﺔ‬
Please declare any of the below cases by marking P under the word Yes ‫ ﻓﻲ ﺍﻟﻤﺮﺑﻊ ﺗﺤﺖ ﻛﻠﻤﺔ ﻧﻌﻢ‬P ‫ﻳﺮﺟﻰ ﺍﻹﻓﺼﺎﺡ ﻋﻦ ﻭﺟﻮﺩ ﺃﻱ ﻣﻦ ﺍﻟﺤﺎﻻﺕ ﺍﺩﻧﺎﻩ ﺑﻮﺿﻊ ﺇﺷﺎﺭﺓ‬
"Below Undeclared Medical Case May Not Be Covered" No / ‫ﻻ‬ Yes / ‫ﻧﻌـﻢ‬ "‫"ﻟﻦ ﺗﺘﻢ ﺍﻟﺘﻐﻄﻴﺔ ﺍﻟﺘﺄﻣﻴﻨﻴﺔ ﻟﻠﺤﺎﻻﺕ ﺃﺩﻧﺎﻩ ﻓﻰ ﺣﺎﻝ ﻋﺪﻡ ﺍﻹﻓﺼﺎﺡ ﻋﻨﻬﺎ‬
Any hospital admission during last 12 months. ‫ ﺷﻬﺮ‬12 ‫ﻫﻞ ﺗﻢ ﺍﻟﺘﻨﻮﻳﻢ ﺑﺎﻟﻤﺴﺘﺸﻔﻰ ﺧﻼﻝ ﺃﺧﺮ‬
"Admission: registering as an admitted patient at the hospital until the following morning "
* * " ‫ ﺗﺴﺠﻴﻞ ﺍﻟﺸﺨﺺ ﺍﻟﻤﺆﻣﻦ ﻟﻪ ﻛﻤﺮﻳﺾ ﻣﻨﻮﻡ ﻓﻲ ﺍﻟﻤﺴﺘﺸﻔﻰ ﺣﺘﻰ ﺻﺒﺎﺡ ﺍﻟﻴﻮﻡ ﺍﻟﺘﺎﻟﻲ‬: ‫" ﺍﻟﺘﻨﻮﻳﻢ‬

Have you been diagnosed with any of the following chronic disease limited ‫ﻫﻞ ﺗﻢ ﺗﺸﺨﻴﺼﻚ ﺑﺄﻯ ﻣﻦ ﺍﻷﻣﺮﺍﺽ ﺍﻟﺘﺎﻟﻴﺔ ﻓﻘﻂ‬
to:Autism, listed Benign Tumor (Breast tumors, fibroid uterus, benign prostatic hyperplasia, ‫ﺃﻭﺭﺍﻡ ﺃﻭ‬,‫ﺗﻀﺨﻢ ﺍﻟﺒﺮﻭﺳﺘﺎﺗﺎ ﺍﻟﺤﻤﻴﺪ‬,‫ ﺃﻭﺭﺍﻡ ﺍﻟﺮﺣﻢ ﺍﻟﻠﻴﻔﻰ‬, ‫ﺍﻻﻭﺭﺍﻡ ﺍﻟﺤﻤﻴﺪﺓ ﺍﻟﺘﺎﻟﻴﺔ )ﺃﻭﺭﺍﻡ ﺍﻟﺜﺪﻯ‬,‫ﺍﻷﻭﺭﺍﻡ ﺍﻟﺴﺮﻃﺎﻧﻴﺔ‬,‫ﺍﻟﺘﻮﺣﺪ‬
thyroid goiter and parathyroid glands, live tumors, colon tumors). Malignant tumors, listed ‫ﺃﻣﺮﺍﺽ ﺍﻟﻘﻠﺐ ﺍﻟﺘﺎﻟﻴﺔ)ﺃﻣﺮﺍﺽ ﺷﺮﺍﻳﻴﻦ ﻭﺻﻤﺎﻣﺎﺕ ﺗﻀﺨﻢ ﺍﻟﻐﺪﺓ ﺍﻟﺪﺭﻗﻴﺔ‬, (‫ﺃﻭﺭﺍﻡ ﺍﻟﻘﻮﻟﻮﻥ‬, ‫ﻭﺃﻭﺭﺍﻡ ﺍﻻﻟﻜﺒﺪ‬,‫ﻭ ﺍﻟﺠﺎﺭ ﺍﻟﺪﺭﻗﻴﺔ‬
Cardiac diseases coronary and valve heart diseases, heart failure, cardiac fibrillation
myocardial infraction, heart clots). Chronic Hepatitis C. Gallstones Sever Kidney failure (stage
* * ‫ﺍﻻﻟﺘﻬﺎﺏ ﺍﻟﻜﺒﺪﻯ ﺍﻟﻔﻴﺮﻭﺳﻰ ﺍﻟﻤﺰﻣﻦ‬.( ‫ﺍﻟﺮﺟﻔﺎﻥ ﺍﻟﻘﻠﺒﻰ ﻭﺟﻠﻄﺎﺕ ﺍﻟﻘﻠﺐ‬, ‫ﻓﺸﻞ ﻋﻀﻠﺔ ﺍﻟﻘﻠﺐ‬, ‫ﺣﺼﻮﺍﺕ ﺍﻟﻤﺮﺍﺭﺓ ﺍﻟﻘﻠﺐ‬, ‫ﺝ ﻭﺳﻰ‬
,‫ ﺍﻟﺘﺮﺷﻴﺢ ﺍﻟﻜﻠﻮﻯ ﺃﻗﻞ ﻣﻦ‬,‫ ﺍﻟﻔﺸﻞ ﺍﻟﻜﻠﻮﻯﺍﻟﺸﺪﻳﺪ )ﺍﻟﻤﺮﺣﻠﺔ ﺍﻟﺨﺎﻣﺴﺔ ﻣﻦ ﺍﻣﺮﺍﺽ ﺍﻟﻜﻠﻰ ﺍﻟﺘﻰ ﺗﺴﺘﺪﻋﻰ ﺍﻟﻐﺴﻴﻞ ﺍﻟﻜﻠﻮﻯ‬15
5 Requiring dialysis, clearance of less tha 15 ml/ minute*). Urinary tract ‫ﻣﺮﺽ‬, ‫ﺩﻗﻴﻘﺔ(ﺣﺼﻮﺍﺕ ﺍﻟﻤﺴﺎﻟﻚ ﺍﻟﺒﻮﻟﻴﺔﺃﻣﺮﺍﺽ ﺍﻟﻤﻨﺎﻋﺔ ﺍﻟﺘﺎﻟﻴﺔ )ﺍﻟﺬﺋﺒﺔ ﺍﻟﺤﻤﺮﺍﺀﻭﺍﻟﺘﻬﺎﺏ ﺍﻟﻤﻔﺎﺻﻞ ﺍﻟﺮﻭﻣﺎﺗﻴﺰﻣﻴﺔﻭ ﺍﻟﺼﺪﻓﻴﺔ‬/‫ﻣﻞ‬
stones, hernias. Autoimmune disease (lupus, rheumatoid arthritis, psoriasis, Crohn's disease, ‫ﺍﻟﺘﻬﺎﺏ ﺍﻟﻘﻮﻟﻮﻥ ﺍﻟﺘﻘﺮﺣﻰ‬, ‫ﻛﺮﻭﻧﺰ‬,
ulcerative colitis,multiple sclerosis, celiac disease) ‫ﺣﺴﺎﺳﻴﺔ ﺍﻟﻘﻤﺢ‬, ‫ﺍﻟﺘﺼﻠﺐ ﺍﻟﻠﻮﻳﺤﻰ‬

Have you been diagnosed with any of the following congenital disorder or
hereditary diseases limited to: Cerebral palsy, Sickle cell disorder, Thalassemia, ‫ﻫﻞ ﺗﻢ ﺗﺸﺨﻴﺼﻚ ﺑﺄﻱ ﻣﻦ ﺍﻷﻣﺮﺍﺽ ﺍﻟﻮﺭﺍﺛﻴﺔ ﺃﻭ ﺍﻟﺘﺸﻮﻫﺎﺕ ﺍﻟﺨﻠﻘﻴﺔ ﺍﻟﺘﺎﻟﻴﺔ ﻓﻘﻂ‬
hemophilia, metabolic diseases, Hydrocephalus, spinal muscle atrophy, genital ‫ ﺿﻤﻮﺭ‬،‫ ﺃﺳﺘﺴﻘﺎﺀ ﺍﻟﺮﺃﺱ‬،‫ ﺃﻣﺮﺍﺽ ﺍﻟﺘﻤﺜﻴﻞ ﺍﻟﻐﺬﺍﺋﻲ‬،‫ ﺍﻟﻬﻴﻤﻮﻓﻴﻠﻴﺎ‬،‫ ﺍﻟﺘﻼﺳﻴﻤﻴﺎ‬،‫ﺍﺿﻄﺮﺍﺏ ﺍﻟﺨﻼﻳﺎ ﺍﻟﻤﻨﺠﻠﻴﺔ‬, ‫ﺍﻟﺸﻠﻞ ﺍﻟﺪﻣﺎﻏﻰ‬
malformations, chromosomal abnormalities. Gaucher's disease, G6PD Deficiency, cystic
fibrosis, hemochromatosis, Wilson disease. Polycystic Kidney Disease.
* * ‫ ﻣﺮﺽ ﺍﻟﺘﻜﺴﺮﺍﻟﻔﻮﻟﻰ‬،‫ ﻣﺮﺽ ﻏﻮﺷﺮ‬،‫ ﺃﻣﺮﺍﺽ ﺍﻟﻜﺮﻭﻣﻮﺳﻮﻣﺎﺕ‬،‫ ﺗﺸﻮﻫﺎﺕ ﺍﻷﻋﻀﺎﺀ ﺍﻟﺘﻨﺎﺳﻠﻴﺔ‬،‫ﺍﻟﻌﻀﻼﺕ ﺍﻟﺸﻮﻛﻲ‬
‫ﺗﻜﻴﺲ‬,‫ﻣﺮﺽ ﻭﻳﻠﺴﻮﻥ‬, (‫ ﻣﺮﺽ ﺗﻜﺪﺱ ﺍﻟﺤﺪﻳﺪ )ﻫﻴﻤﻮﻛﺮﻭﻣﺎﺗﻮﺳﻴﺲ‬،‫( ﺍﻟﺘﻠﻴﻒ ﺍﻟﻜﻴﺴﻲ ﻟﻠﺮﺋﺔ‬G6PD)
‫ﺍﻟﻜﻠﻴﺘﻴﻦ ﺍﻟﺨﻠﻔﻰ ﺍﻟﻮﺭﺍﺋﻰ‬

Have you been diagnosed with any of following eye diseases limited to: ،‫ ﻣﻴﺎﺓ ﺯﺭﻗﺎﺀ‬،‫ ﻣﻴﺎﺓ ﺑﻴﻀﺎﺀ‬:‫ﻫﻞ ﺗﻢ ﺗﺸﺨﻴﺼﻚ ﺑﺄﻱ ﻣﻦ ﺃﻣﺮﺍﺽ ﺍﻟﻌﻴﻦ ﺍﻟﺘﺎﻟﻴﺔ ﻓﻘﻂ‬
Cataract, Glaucoma, Retinal diseases. * * ‫ﺃﻣﺮﺍﺽ ﺍﻟﺸﺒﻜﻴﺔ‬
Have you been diagnosed with any of the following bone diseases limited ‫ ﺍﻹﻧﺰﻻﻕ ﺍﻟﻐﻀﺮﻭﻓﻲ‬:‫ﻫﻞ ﺗﻢ ﺗﺸﺨﻴﺼﻚ ﺑﺄﻱ ﻣﻦ ﺃﻣﺮﺍﺽ ﺍﻟﻌﻈﺎﻡ ﺍﻟﺘﺎﻟﻴﺔ ﻓﻘﻂ‬
to:Vertebral disc prolapse (moderate or severe), Scoliosis (moderate or severe)**, or ligament
tears, osteoarthritis (moderate or severe )
* * ‫ﺗﻤﺰﻕ ﺍﻷﺭﺑﻄﺔ‬،‫ﺍﻟﺘﻬﺎﺏ ﺍﻟﻤﻔﺎﺻﻞ‬،‫ﺇﻧﺤﺮﺍﻑ ﺍﻟﻌﻤﻮﺩ ﺍﻟﻔﻘﺮﻱ‬,‫ﺍﻟﺪﻳﺴﻚ‬

Pregnant Female Only ‫ﻟﻸﻧﺜﻰ ﺍﻟﺤﺎﻣﻞ ﻓﻘﻂ‬

‫ﺣﻤﻞ ﺣﺎﻟﻲ ﺟﻨﻴﻦ ﻭﺍﺣﺪ‬
Current Single Pregnancy
* *
‫ﺣﻤﻞ ﺣﺎﻟﻲ ﻣﻊ ﻗﻴﺼﺮﻳﺔ ﺳﺎﺑﻘﺔ‬
Current Single Pregnancy with Previous CS Delivery
* *
‫ﺣﻤﻞ ﺣﺎﻟﻲ ﻣﺘﻌﺪﺩ ﺍﻷﺟﻨﺔ‬
Current Multiple Pregnancy
* *
Expected delivery date .. / .. / .... ‫ﺗﺎﺭﻳﺦ ﺍﻟﻮﻻﺩﺓ ﺍﻟﻤﺘﻮﻗﻊ‬
Employee and dependents details that need to be added ‫ﺑﻴﺎﻧﺎﺕ ﺍﻟﻤﻮﻇﻒ ﻭﺃﻓﺮﺍﺩ ﺍﻟﻌﺎﺋﻠﺔ ﺍﻟﻤﺮﺍﺩ ﺇﺿﺎﻓﺘﻬﻢ‬
In case of a yes answer above, please declare the case in the table below ‫ ﺍﻟﺮﺟﺎﺀ ﺫﻛﺮ ﺍﻟﺤﺎﻟﺔ ﻓﻲ ﺍﻟﺠﺪﻭﻝ ﺃﺩﻧﺎﻩ‬،‫ﻓﻲ ﺣﺎﻟﺔ ﺍﻹﺟﺎﺑﺔ ﺑﻨﻌﻢ ﺃﻋﻼﻩ‬
‫ﺇﺳﻢ ﻣﻘﺪﻡ ﺍﻟﺨﺪﻣﺔ‬ ‫ﺍﻟﺤﺎﻟﺔ‬ ‫ﺭﻗﻢ ﺍﻟﺠﻮﺍﻝ‬ ‫ﺍﻟﻄﻮﻝ‬ ‫ﺍﻟﻮﺯﻥ‬ ‫ﺭﻗﻢ ﺍﻟﻬﻮﻳﺔ‬ ‫ﺍﻟﻘﺮﺍﺑﺔ‬ ‫ﺍﻟﺠﻨﺲ‬ ‫ ﺃﻓﺮﺍﺩ ﺍﻟﻌﺎﺋﻠﺔ‬/ ‫ﺍﺳﻢ ﺍﻟﻤﻮﻇﻒ‬ ‫ﻡ‬
2423899802 Child Male / ‫ ﺫﻛﺮ‬Saad Tahir Khaliqullah Walimo 1
2
3
4
5
Undertakings : ‫ﺍﻹﻗﺮﺍﺭ ﻭﺍﻟﺘﻔﻮﻳﺾ‬
1- I hereby undertake that all the above information is correct and the acceptance of my ‫ﻭﺍﻟﻤﻌﻠﻮﻣﺎﺕ ﺍﻟﻤﺬﻛﻮﺭﺓ ﺃﻋﻼﻩ ﻛﺎﻣﻠﺔ ﻭﺻﺤﻴﺤﺔ ﻭﺑﻨﺎﺀ ﻋﻠﻴﻪ ﻓﺈﻥ ﻗﺒﻮﻝ ﺍﻟﻄﻠﺐ ﺳﻴﺘﻢ‬: ‫ ﺃﻗﺮ ﺃﻥ ﺍﻟﺒﻴﺎﻧﺎﺕ‬-1
enrollment will be on the basis of such information and that Malath Cooperative Insurance ‫ﻋﻠﻰ ﺃﺳﺎﺱ ﻫﺬﻩ ﺍﻟﺒﻴﺎﻧﺎﺕ ﻭﺃﻥ ﺷﺮﻛﺔ ﻣﻼﺫ ﻟﻠﺘﺄﻣﻴﻦ ﺍﻟﺘﻌﺎﻭﻧﻲ ﻟﻬﺎ ﺍﻟﺤﻖ ﻓﻲ ﺍﻻﺗﺼﺎﻝ ﺑﺎﻟﻤﺴﺘﺸﻔﻴﺎﺕ ﺍﻟﺘﻲ‬
Company has the right to contact the hospital(s) I deal with to collect any ‫ﺃﺗﻌﺎﻣﻞ ﻣﻌﻬﺎ ﻟﺘﺰﻭﻳﺪﻫﺎ ﺑﺄﻱ ﻣﻌﻠﻮﻣﺎﺕ ﻃﺒﻴﺔ ﻗﺪ ﺗﺤﺘﺎﺝ ﺇﻟﻴﻬﺎ ﻟﺘﻘﻴﻴﻢ ﺍﻟﻤﺨﺎﻃﺮ‬
medical information needed to assess the risk(s).

2- I agree that Malath Cooperative Insurance Company has the right to reject the ‫ ﺃﻭﺍﻓﻖ ﻋﻠﻰ ﺃﺣﻘﻴﺔ ﺷﺮﻛﺔ ﻣﻼﺫ ﻟﻠﺘﺄﻣﻴﻦ ﻓﻲ ﺭﻓﺾ ﺍﻟﻤﻄﺎﻟﺒﺔ ﺃﻭ ﺍﻟﺘﻐﻄﻴﺔ ﻛﻠﻴﺎ ﻋﻨﺪ ﻋﺪﻡ ﺍﻹﻓﺼﺎﺡ ﻋﻦ ﻭﺟﻮﺩ ﺃﻱ ﻣﻦ ﺍﻟﺤﺎﻻﺕ‬-2
coverage/claims in full in case of no declaration of any cases prior to the contractual date or ‫ﺍﻟﻤﺬﻛﻮﺭﺓ ﺃﻋﻼﻩ ﺍﻟﺘﻲ ﻧﺸﺄﺕ ﻗﺒﻞ ﺗﺎﺭﻳﺦ ﺍﻟﺘﻌﺎﻗﺪ ﺃﻭ ﻗﺒﻞ ﺗﺴﺠﻴﻞ ﺃﻭ ﺇﺿﺎﻓﺔ ﻋﻀﻮ ﺧﻼﻝ ﻓﺘﺮﺓ ﺳﺮﻳﺎﻥ ﺍﻟﻌﻘﺪ‬
before enrolling or adding a new member during the contract.

3- I hereby confirm reading and understanding all points presented in this form and I agree that ‫ ﺃﻗﺮﺑﺄﻧﻲ ﻗﺪ ﻗﺮﺃﺕ ﻭﻓﻬﻤﺖ ﺟﻤﻴﻊ ﻣﺎ ﺟﺎﺀ ﻓﻲ ﻫﺬﺍ ﺍﻟﻨﻤﻮﺫﺝ ﻛﻤﺎ ﺃﺗﻌﻬﺪ ﺑﺄﻥ ﻋﺪﻡ ﺇﺷﺎﺭﺗﻲ ﺃﻣﺎﻡ ﺃﻱ ﻣﻦ‬-3
not marking any case is understood as “Nothing requires declaration” and I sign on these ‫ﺍﻟﺤﺎﻻﺕ ﺍﻟﻤﺬﻛﻮﺭﺓ ﺃﻋﻼﻩ ﻳﻌﺘﺒﺮ ﺑﻤﺜﺎﺑﺔ ﻧﻔﻲ ﻭﺟﻮﺩ ﻣﺎﻳﺴﺘﺤﻖ ﺍﻹﻓﺼﺎﺡ ﻋﻨﻪ ﻭﻋﻠﻴﻪ ﺃﻭﻗﻊ‬
basis.
4- Failure to fill the weight and height information will result in refusal to cover
the cost of obesity surgery. ‫ ﻋﺪﻡ ﺗﻌﺒﺌﺔ ﺑﻴﺎﻧﺎﺕ ﺍﻟﻄﻮﻝ ﻭﺍﻟﻮﺯﻥ ﺳﻴﺆﺩﻱ ﺇﻟﻰ ﺭﻓﺾ ﺗﻐﻄﻴﺔ ﺗﻜﺎﻟﻴﻒ ﻋﻤﻠﻴﺔ ﺟﺮﺍﺣﺔ ﺍﻟﺴﻤﻨﺔ ﺍﻟﻤﻔﺮﻃﺔ‬-4

Entity's stamp ‫ﺧﺘﻢ ﺟﻬﺔ ﺍﻟﻌﻤﻞ‬ Insured Signature ‫ﺗﻮﻗﻴﻊ ﺍﻟﻤﻮﻇﻒ‬ Date ‫ﺍﻟﺘﺎﺭﻳﺦ‬
.. / .. / ....

New_Health_Insurance.rdf Page 9 of 39 V.20 13-DEC-2023 01:30 PM

 ‫ﻧﻤﻮﺫﺝ ﺍﻻﻓﺼﺎﺡ ﺍﻟﻄﺒﻲ ﺍﻟﻤﻮﺣﺪ‬
Unified Medical Declaration Form
Product Code: A-MLTH-2-C-08-014
Dear Insured: ‫ﻋﺰﻳﺰﻱ ﺍﻟﻤﺆﻣﻦ ﻟﻪ‬
Please Fill out the form correctly for the purpose of pricing and to ensured that you and your ‫ﻧﺄﻣﻞ ﻗﻴﺎﻣﻚ ﺑﺘﻌﺒﺌﺔ ﻫﺬﺍ ﺍﻟﻨﻤﻮﺫﺝ ﺑﺎﻟﺸﻜﻞ ﺍﻟﺼﺤﻴﺢ ﻟﻐﺮﺽ ﺍﻟﺘﺴﻌﻴﺮ ﻭﻟﻀﻤﺎﻥ ﺣﺼﻮﻟﻚ ﻭﺃﻓﺮﺍﺩ ﺃﺳﺮﺗﻚ ﻋﻠﻰ ﺧﺪﻣﺎﺕ‬
family receive health care services as required according to your unfied policy benefit ‫ﺍﻟﺮﻋﺎﻳﺔ ﺍﻟﺼﺤﻴﺔ ﺑﺎﻟﺸﻜﻞ ﺍﻟﻤﻄﻠﻮﺏ ﺣﺴﺐ ﻣﻨﺎﻓﻊ ﺍﻟﻮﺛﻴﻘﺔ ﺍﻟﻤﻮﺣﺪﺓ‬

Addition ‫ﺇﺿﺎﻓﺔ‬ New ‫ﺟﺪﻳﺪ‬ Type ‫ﻧﻮﻉ ﺍﻟﻄﻠﺐ‬

CR No 7011507360 ‫ﺍﻟﺴﺠﻞ ﺍﻟﺘﺠﺎﺭﻱ‬ Entity Name HADDAJ AL HIJAZ EST ‫ﺃﺳﻢ ﺍﻟﻤﻨﺸﺄﺓ‬
Mobile No 0509300773 ‫ﺭﻗﻢ ﺍﻟﺠﻮﺍﻝ‬ Mohammed Khaliq Ullah ‫ﺍﺳﻢ ﺍﻟﻤﻮﻇﻒ‬
ID Number 2 0 1 6 7 6 8 6 5 3 ‫ﺭﻗﻢ ﺍﻟﻬﻮﻳﺔ‬
Male / ‫ﺫﻛﺮ‬ India
Gender ‫ ﺍﻟﺠﻨﺲ‬Nationality ‫ ﺍﻟﺠﻨﺴﻴﺔ‬Marital status Married R ‫ﻣﺘﺰﻭﺝ‬ Single * ‫ﺃﻋﺰﺏ‬ ‫ﺍﻟﺤﺎﻟﺔ ﺍﻻﺟﺘﻤﺎﻋﻴﺔ‬
Please declare any of the below cases by marking P under the word Yes ‫ ﻓﻲ ﺍﻟﻤﺮﺑﻊ ﺗﺤﺖ ﻛﻠﻤﺔ ﻧﻌﻢ‬P ‫ﻳﺮﺟﻰ ﺍﻹﻓﺼﺎﺡ ﻋﻦ ﻭﺟﻮﺩ ﺃﻱ ﻣﻦ ﺍﻟﺤﺎﻻﺕ ﺍﺩﻧﺎﻩ ﺑﻮﺿﻊ ﺇﺷﺎﺭﺓ‬
"Below Undeclared Medical Case May Not Be Covered" No / ‫ﻻ‬ Yes / ‫ﻧﻌـﻢ‬ "‫"ﻟﻦ ﺗﺘﻢ ﺍﻟﺘﻐﻄﻴﺔ ﺍﻟﺘﺄﻣﻴﻨﻴﺔ ﻟﻠﺤﺎﻻﺕ ﺃﺩﻧﺎﻩ ﻓﻰ ﺣﺎﻝ ﻋﺪﻡ ﺍﻹﻓﺼﺎﺡ ﻋﻨﻬﺎ‬
Any hospital admission during last 12 months. ‫ ﺷﻬﺮ‬12 ‫ﻫﻞ ﺗﻢ ﺍﻟﺘﻨﻮﻳﻢ ﺑﺎﻟﻤﺴﺘﺸﻔﻰ ﺧﻼﻝ ﺃﺧﺮ‬
"Admission: registering as an admitted patient at the hospital until the following morning "
* * " ‫ ﺗﺴﺠﻴﻞ ﺍﻟﺸﺨﺺ ﺍﻟﻤﺆﻣﻦ ﻟﻪ ﻛﻤﺮﻳﺾ ﻣﻨﻮﻡ ﻓﻲ ﺍﻟﻤﺴﺘﺸﻔﻰ ﺣﺘﻰ ﺻﺒﺎﺡ ﺍﻟﻴﻮﻡ ﺍﻟﺘﺎﻟﻲ‬: ‫" ﺍﻟﺘﻨﻮﻳﻢ‬

Have you been diagnosed with any of the following chronic disease limited ‫ﻫﻞ ﺗﻢ ﺗﺸﺨﻴﺼﻚ ﺑﺄﻯ ﻣﻦ ﺍﻷﻣﺮﺍﺽ ﺍﻟﺘﺎﻟﻴﺔ ﻓﻘﻂ‬
to:Autism, listed Benign Tumor (Breast tumors, fibroid uterus, benign prostatic hyperplasia, ‫ﺃﻭﺭﺍﻡ ﺃﻭ‬,‫ﺗﻀﺨﻢ ﺍﻟﺒﺮﻭﺳﺘﺎﺗﺎ ﺍﻟﺤﻤﻴﺪ‬,‫ ﺃﻭﺭﺍﻡ ﺍﻟﺮﺣﻢ ﺍﻟﻠﻴﻔﻰ‬, ‫ﺍﻻﻭﺭﺍﻡ ﺍﻟﺤﻤﻴﺪﺓ ﺍﻟﺘﺎﻟﻴﺔ )ﺃﻭﺭﺍﻡ ﺍﻟﺜﺪﻯ‬,‫ﺍﻷﻭﺭﺍﻡ ﺍﻟﺴﺮﻃﺎﻧﻴﺔ‬,‫ﺍﻟﺘﻮﺣﺪ‬
thyroid goiter and parathyroid glands, live tumors, colon tumors). Malignant tumors, listed ‫ﺃﻣﺮﺍﺽ ﺍﻟﻘﻠﺐ ﺍﻟﺘﺎﻟﻴﺔ)ﺃﻣﺮﺍﺽ ﺷﺮﺍﻳﻴﻦ ﻭﺻﻤﺎﻣﺎﺕ ﺗﻀﺨﻢ ﺍﻟﻐﺪﺓ ﺍﻟﺪﺭﻗﻴﺔ‬, (‫ﺃﻭﺭﺍﻡ ﺍﻟﻘﻮﻟﻮﻥ‬, ‫ﻭﺃﻭﺭﺍﻡ ﺍﻻﻟﻜﺒﺪ‬,‫ﻭ ﺍﻟﺠﺎﺭ ﺍﻟﺪﺭﻗﻴﺔ‬
Cardiac diseases coronary and valve heart diseases, heart failure, cardiac fibrillation
myocardial infraction, heart clots). Chronic Hepatitis C. Gallstones Sever Kidney failure (stage
* * ‫ﺍﻻﻟﺘﻬﺎﺏ ﺍﻟﻜﺒﺪﻯ ﺍﻟﻔﻴﺮﻭﺳﻰ ﺍﻟﻤﺰﻣﻦ‬.( ‫ﺍﻟﺮﺟﻔﺎﻥ ﺍﻟﻘﻠﺒﻰ ﻭﺟﻠﻄﺎﺕ ﺍﻟﻘﻠﺐ‬, ‫ﻓﺸﻞ ﻋﻀﻠﺔ ﺍﻟﻘﻠﺐ‬, ‫ﺣﺼﻮﺍﺕ ﺍﻟﻤﺮﺍﺭﺓ ﺍﻟﻘﻠﺐ‬, ‫ﺝ ﻭﺳﻰ‬
,‫ ﺍﻟﺘﺮﺷﻴﺢ ﺍﻟﻜﻠﻮﻯ ﺃﻗﻞ ﻣﻦ‬,‫ ﺍﻟﻔﺸﻞ ﺍﻟﻜﻠﻮﻯﺍﻟﺸﺪﻳﺪ )ﺍﻟﻤﺮﺣﻠﺔ ﺍﻟﺨﺎﻣﺴﺔ ﻣﻦ ﺍﻣﺮﺍﺽ ﺍﻟﻜﻠﻰ ﺍﻟﺘﻰ ﺗﺴﺘﺪﻋﻰ ﺍﻟﻐﺴﻴﻞ ﺍﻟﻜﻠﻮﻯ‬15
5 Requiring dialysis, clearance of less tha 15 ml/ minute*). Urinary tract ‫ﻣﺮﺽ‬, ‫ﺩﻗﻴﻘﺔ(ﺣﺼﻮﺍﺕ ﺍﻟﻤﺴﺎﻟﻚ ﺍﻟﺒﻮﻟﻴﺔﺃﻣﺮﺍﺽ ﺍﻟﻤﻨﺎﻋﺔ ﺍﻟﺘﺎﻟﻴﺔ )ﺍﻟﺬﺋﺒﺔ ﺍﻟﺤﻤﺮﺍﺀﻭﺍﻟﺘﻬﺎﺏ ﺍﻟﻤﻔﺎﺻﻞ ﺍﻟﺮﻭﻣﺎﺗﻴﺰﻣﻴﺔﻭ ﺍﻟﺼﺪﻓﻴﺔ‬/‫ﻣﻞ‬
stones, hernias. Autoimmune disease (lupus, rheumatoid arthritis, psoriasis, Crohn's disease, ‫ﺍﻟﺘﻬﺎﺏ ﺍﻟﻘﻮﻟﻮﻥ ﺍﻟﺘﻘﺮﺣﻰ‬, ‫ﻛﺮﻭﻧﺰ‬,
ulcerative colitis,multiple sclerosis, celiac disease) ‫ﺣﺴﺎﺳﻴﺔ ﺍﻟﻘﻤﺢ‬, ‫ﺍﻟﺘﺼﻠﺐ ﺍﻟﻠﻮﻳﺤﻰ‬

Have you been diagnosed with any of the following congenital disorder or
hereditary diseases limited to: Cerebral palsy, Sickle cell disorder, Thalassemia, ‫ﻫﻞ ﺗﻢ ﺗﺸﺨﻴﺼﻚ ﺑﺄﻱ ﻣﻦ ﺍﻷﻣﺮﺍﺽ ﺍﻟﻮﺭﺍﺛﻴﺔ ﺃﻭ ﺍﻟﺘﺸﻮﻫﺎﺕ ﺍﻟﺨﻠﻘﻴﺔ ﺍﻟﺘﺎﻟﻴﺔ ﻓﻘﻂ‬
hemophilia, metabolic diseases, Hydrocephalus, spinal muscle atrophy, genital ‫ ﺿﻤﻮﺭ‬،‫ ﺃﺳﺘﺴﻘﺎﺀ ﺍﻟﺮﺃﺱ‬،‫ ﺃﻣﺮﺍﺽ ﺍﻟﺘﻤﺜﻴﻞ ﺍﻟﻐﺬﺍﺋﻲ‬،‫ ﺍﻟﻬﻴﻤﻮﻓﻴﻠﻴﺎ‬،‫ ﺍﻟﺘﻼﺳﻴﻤﻴﺎ‬،‫ﺍﺿﻄﺮﺍﺏ ﺍﻟﺨﻼﻳﺎ ﺍﻟﻤﻨﺠﻠﻴﺔ‬, ‫ﺍﻟﺸﻠﻞ ﺍﻟﺪﻣﺎﻏﻰ‬
malformations, chromosomal abnormalities. Gaucher's disease, G6PD Deficiency, cystic
fibrosis, hemochromatosis, Wilson disease. Polycystic Kidney Disease.
* * ‫ ﻣﺮﺽ ﺍﻟﺘﻜﺴﺮﺍﻟﻔﻮﻟﻰ‬،‫ ﻣﺮﺽ ﻏﻮﺷﺮ‬،‫ ﺃﻣﺮﺍﺽ ﺍﻟﻜﺮﻭﻣﻮﺳﻮﻣﺎﺕ‬،‫ ﺗﺸﻮﻫﺎﺕ ﺍﻷﻋﻀﺎﺀ ﺍﻟﺘﻨﺎﺳﻠﻴﺔ‬،‫ﺍﻟﻌﻀﻼﺕ ﺍﻟﺸﻮﻛﻲ‬
‫ﺗﻜﻴﺲ‬,‫ﻣﺮﺽ ﻭﻳﻠﺴﻮﻥ‬, (‫ ﻣﺮﺽ ﺗﻜﺪﺱ ﺍﻟﺤﺪﻳﺪ )ﻫﻴﻤﻮﻛﺮﻭﻣﺎﺗﻮﺳﻴﺲ‬،‫( ﺍﻟﺘﻠﻴﻒ ﺍﻟﻜﻴﺴﻲ ﻟﻠﺮﺋﺔ‬G6PD)
‫ﺍﻟﻜﻠﻴﺘﻴﻦ ﺍﻟﺨﻠﻔﻰ ﺍﻟﻮﺭﺍﺋﻰ‬

Have you been diagnosed with any of following eye diseases limited to: ،‫ ﻣﻴﺎﺓ ﺯﺭﻗﺎﺀ‬،‫ ﻣﻴﺎﺓ ﺑﻴﻀﺎﺀ‬:‫ﻫﻞ ﺗﻢ ﺗﺸﺨﻴﺼﻚ ﺑﺄﻱ ﻣﻦ ﺃﻣﺮﺍﺽ ﺍﻟﻌﻴﻦ ﺍﻟﺘﺎﻟﻴﺔ ﻓﻘﻂ‬
Cataract, Glaucoma, Retinal diseases. * * ‫ﺃﻣﺮﺍﺽ ﺍﻟﺸﺒﻜﻴﺔ‬
Have you been diagnosed with any of the following bone diseases limited ‫ ﺍﻹﻧﺰﻻﻕ ﺍﻟﻐﻀﺮﻭﻓﻲ‬:‫ﻫﻞ ﺗﻢ ﺗﺸﺨﻴﺼﻚ ﺑﺄﻱ ﻣﻦ ﺃﻣﺮﺍﺽ ﺍﻟﻌﻈﺎﻡ ﺍﻟﺘﺎﻟﻴﺔ ﻓﻘﻂ‬
to:Vertebral disc prolapse (moderate or severe), Scoliosis (moderate or severe)**, or ligament
tears, osteoarthritis (moderate or severe )
* * ‫ﺗﻤﺰﻕ ﺍﻷﺭﺑﻄﺔ‬،‫ﺍﻟﺘﻬﺎﺏ ﺍﻟﻤﻔﺎﺻﻞ‬،‫ﺇﻧﺤﺮﺍﻑ ﺍﻟﻌﻤﻮﺩ ﺍﻟﻔﻘﺮﻱ‬,‫ﺍﻟﺪﻳﺴﻚ‬

Pregnant Female Only ‫ﻟﻸﻧﺜﻰ ﺍﻟﺤﺎﻣﻞ ﻓﻘﻂ‬

‫ﺣﻤﻞ ﺣﺎﻟﻲ ﺟﻨﻴﻦ ﻭﺍﺣﺪ‬
Current Single Pregnancy
* *
‫ﺣﻤﻞ ﺣﺎﻟﻲ ﻣﻊ ﻗﻴﺼﺮﻳﺔ ﺳﺎﺑﻘﺔ‬
Current Single Pregnancy with Previous CS Delivery
* *
‫ﺣﻤﻞ ﺣﺎﻟﻲ ﻣﺘﻌﺪﺩ ﺍﻷﺟﻨﺔ‬
Current Multiple Pregnancy
* *
Expected delivery date .. / .. / .... ‫ﺗﺎﺭﻳﺦ ﺍﻟﻮﻻﺩﺓ ﺍﻟﻤﺘﻮﻗﻊ‬
Employee and dependents details that need to be added ‫ﺑﻴﺎﻧﺎﺕ ﺍﻟﻤﻮﻇﻒ ﻭﺃﻓﺮﺍﺩ ﺍﻟﻌﺎﺋﻠﺔ ﺍﻟﻤﺮﺍﺩ ﺇﺿﺎﻓﺘﻬﻢ‬
In case of a yes answer above, please declare the case in the table below ‫ ﺍﻟﺮﺟﺎﺀ ﺫﻛﺮ ﺍﻟﺤﺎﻟﺔ ﻓﻲ ﺍﻟﺠﺪﻭﻝ ﺃﺩﻧﺎﻩ‬،‫ﻓﻲ ﺣﺎﻟﺔ ﺍﻹﺟﺎﺑﺔ ﺑﻨﻌﻢ ﺃﻋﻼﻩ‬
‫ﺇﺳﻢ ﻣﻘﺪﻡ ﺍﻟﺨﺪﻣﺔ‬ ‫ﺍﻟﺤﺎﻟﺔ‬ ‫ﺭﻗﻢ ﺍﻟﺠﻮﺍﻝ‬ ‫ﺍﻟﻄﻮﻝ‬ ‫ﺍﻟﻮﺯﻥ‬ ‫ﺭﻗﻢ ﺍﻟﻬﻮﻳﺔ‬ ‫ﺍﻟﻘﺮﺍﺑﺔ‬ ‫ﺍﻟﺠﻨﺲ‬ ‫ ﺃﻓﺮﺍﺩ ﺍﻟﻌﺎﺋﻠﺔ‬/ ‫ﺍﺳﻢ ﺍﻟﻤﻮﻇﻒ‬ ‫ﻡ‬
2016768653 Employee Male / ‫ ﺫﻛﺮ‬Mohammed Khaliq Ullah 1
2
3
4
5
Undertakings : ‫ﺍﻹﻗﺮﺍﺭ ﻭﺍﻟﺘﻔﻮﻳﺾ‬
1- I hereby undertake that all the above information is correct and the acceptance of my ‫ﻭﺍﻟﻤﻌﻠﻮﻣﺎﺕ ﺍﻟﻤﺬﻛﻮﺭﺓ ﺃﻋﻼﻩ ﻛﺎﻣﻠﺔ ﻭﺻﺤﻴﺤﺔ ﻭﺑﻨﺎﺀ ﻋﻠﻴﻪ ﻓﺈﻥ ﻗﺒﻮﻝ ﺍﻟﻄﻠﺐ ﺳﻴﺘﻢ‬: ‫ ﺃﻗﺮ ﺃﻥ ﺍﻟﺒﻴﺎﻧﺎﺕ‬-1
enrollment will be on the basis of such information and that Malath Cooperative Insurance ‫ﻋﻠﻰ ﺃﺳﺎﺱ ﻫﺬﻩ ﺍﻟﺒﻴﺎﻧﺎﺕ ﻭﺃﻥ ﺷﺮﻛﺔ ﻣﻼﺫ ﻟﻠﺘﺄﻣﻴﻦ ﺍﻟﺘﻌﺎﻭﻧﻲ ﻟﻬﺎ ﺍﻟﺤﻖ ﻓﻲ ﺍﻻﺗﺼﺎﻝ ﺑﺎﻟﻤﺴﺘﺸﻔﻴﺎﺕ ﺍﻟﺘﻲ‬
Company has the right to contact the hospital(s) I deal with to collect any ‫ﺃﺗﻌﺎﻣﻞ ﻣﻌﻬﺎ ﻟﺘﺰﻭﻳﺪﻫﺎ ﺑﺄﻱ ﻣﻌﻠﻮﻣﺎﺕ ﻃﺒﻴﺔ ﻗﺪ ﺗﺤﺘﺎﺝ ﺇﻟﻴﻬﺎ ﻟﺘﻘﻴﻴﻢ ﺍﻟﻤﺨﺎﻃﺮ‬
medical information needed to assess the risk(s).

2- I agree that Malath Cooperative Insurance Company has the right to reject the ‫ ﺃﻭﺍﻓﻖ ﻋﻠﻰ ﺃﺣﻘﻴﺔ ﺷﺮﻛﺔ ﻣﻼﺫ ﻟﻠﺘﺄﻣﻴﻦ ﻓﻲ ﺭﻓﺾ ﺍﻟﻤﻄﺎﻟﺒﺔ ﺃﻭ ﺍﻟﺘﻐﻄﻴﺔ ﻛﻠﻴﺎ ﻋﻨﺪ ﻋﺪﻡ ﺍﻹﻓﺼﺎﺡ ﻋﻦ ﻭﺟﻮﺩ ﺃﻱ ﻣﻦ ﺍﻟﺤﺎﻻﺕ‬-2
coverage/claims in full in case of no declaration of any cases prior to the contractual date or ‫ﺍﻟﻤﺬﻛﻮﺭﺓ ﺃﻋﻼﻩ ﺍﻟﺘﻲ ﻧﺸﺄﺕ ﻗﺒﻞ ﺗﺎﺭﻳﺦ ﺍﻟﺘﻌﺎﻗﺪ ﺃﻭ ﻗﺒﻞ ﺗﺴﺠﻴﻞ ﺃﻭ ﺇﺿﺎﻓﺔ ﻋﻀﻮ ﺧﻼﻝ ﻓﺘﺮﺓ ﺳﺮﻳﺎﻥ ﺍﻟﻌﻘﺪ‬
before enrolling or adding a new member during the contract.

3- I hereby confirm reading and understanding all points presented in this form and I agree that ‫ ﺃﻗﺮﺑﺄﻧﻲ ﻗﺪ ﻗﺮﺃﺕ ﻭﻓﻬﻤﺖ ﺟﻤﻴﻊ ﻣﺎ ﺟﺎﺀ ﻓﻲ ﻫﺬﺍ ﺍﻟﻨﻤﻮﺫﺝ ﻛﻤﺎ ﺃﺗﻌﻬﺪ ﺑﺄﻥ ﻋﺪﻡ ﺇﺷﺎﺭﺗﻲ ﺃﻣﺎﻡ ﺃﻱ ﻣﻦ‬-3
not marking any case is understood as “Nothing requires declaration” and I sign on these ‫ﺍﻟﺤﺎﻻﺕ ﺍﻟﻤﺬﻛﻮﺭﺓ ﺃﻋﻼﻩ ﻳﻌﺘﺒﺮ ﺑﻤﺜﺎﺑﺔ ﻧﻔﻲ ﻭﺟﻮﺩ ﻣﺎﻳﺴﺘﺤﻖ ﺍﻹﻓﺼﺎﺡ ﻋﻨﻪ ﻭﻋﻠﻴﻪ ﺃﻭﻗﻊ‬
basis.
4- Failure to fill the weight and height information will result in refusal to cover
the cost of obesity surgery. ‫ ﻋﺪﻡ ﺗﻌﺒﺌﺔ ﺑﻴﺎﻧﺎﺕ ﺍﻟﻄﻮﻝ ﻭﺍﻟﻮﺯﻥ ﺳﻴﺆﺩﻱ ﺇﻟﻰ ﺭﻓﺾ ﺗﻐﻄﻴﺔ ﺗﻜﺎﻟﻴﻒ ﻋﻤﻠﻴﺔ ﺟﺮﺍﺣﺔ ﺍﻟﺴﻤﻨﺔ ﺍﻟﻤﻔﺮﻃﺔ‬-4

Entity's stamp ‫ﺧﺘﻢ ﺟﻬﺔ ﺍﻟﻌﻤﻞ‬ Insured Signature ‫ﺗﻮﻗﻴﻊ ﺍﻟﻤﻮﻇﻒ‬ Date ‫ﺍﻟﺘﺎﺭﻳﺦ‬
.. / .. / ....

New_Health_Insurance.rdf Page 10 of 39 V.20 13-DEC-2023 01:30 PM

 ‫ﻧﻤﻮﺫﺝ ﺍﻻﻓﺼﺎﺡ ﺍﻟﻄﺒﻲ ﺍﻟﻤﻮﺣﺪ‬
Unified Medical Declaration Form
Product Code: A-MLTH-2-C-08-014
Dear Insured: ‫ﻋﺰﻳﺰﻱ ﺍﻟﻤﺆﻣﻦ ﻟﻪ‬
Please Fill out the form correctly for the purpose of pricing and to ensured that you and your ‫ﻧﺄﻣﻞ ﻗﻴﺎﻣﻚ ﺑﺘﻌﺒﺌﺔ ﻫﺬﺍ ﺍﻟﻨﻤﻮﺫﺝ ﺑﺎﻟﺸﻜﻞ ﺍﻟﺼﺤﻴﺢ ﻟﻐﺮﺽ ﺍﻟﺘﺴﻌﻴﺮ ﻭﻟﻀﻤﺎﻥ ﺣﺼﻮﻟﻚ ﻭﺃﻓﺮﺍﺩ ﺃﺳﺮﺗﻚ ﻋﻠﻰ ﺧﺪﻣﺎﺕ‬
family receive health care services as required according to your unfied policy benefit ‫ﺍﻟﺮﻋﺎﻳﺔ ﺍﻟﺼﺤﻴﺔ ﺑﺎﻟﺸﻜﻞ ﺍﻟﻤﻄﻠﻮﺏ ﺣﺴﺐ ﻣﻨﺎﻓﻊ ﺍﻟﻮﺛﻴﻘﺔ ﺍﻟﻤﻮﺣﺪﺓ‬

Addition ‫ﺇﺿﺎﻓﺔ‬ New ‫ﺟﺪﻳﺪ‬ Type ‫ﻧﻮﻉ ﺍﻟﻄﻠﺐ‬

CR No 7011507360 ‫ﺍﻟﺴﺠﻞ ﺍﻟﺘﺠﺎﺭﻱ‬ Entity Name HADDAJ AL HIJAZ EST ‫ﺃﺳﻢ ﺍﻟﻤﻨﺸﺄﺓ‬
Mobile No 0509300773 ‫ﺭﻗﻢ ﺍﻟﺠﻮﺍﻝ‬ Zainab Parween - - Mohammad Husain ‫ﺍﺳﻢ ﺍﻟﻤﻮﻇﻒ‬
ID Number 2 2 6 0 2 9 3 5 8 0 ‫ﺭﻗﻢ ﺍﻟﻬﻮﻳﺔ‬
Gender Female / ‫ﺍﻟﺠﻨﺲ ﺃﻧﺜﻰ‬ Nationality India ‫ ﺍﻟﺠﻨﺴﻴﺔ‬Marital status Married R ‫ﻣﺘﺰﻭﺝ‬ Single * ‫ﺃﻋﺰﺏ‬ ‫ﺍﻟﺤﺎﻟﺔ ﺍﻻﺟﺘﻤﺎﻋﻴﺔ‬
Please declare any of the below cases by marking P under the word Yes ‫ ﻓﻲ ﺍﻟﻤﺮﺑﻊ ﺗﺤﺖ ﻛﻠﻤﺔ ﻧﻌﻢ‬P ‫ﻳﺮﺟﻰ ﺍﻹﻓﺼﺎﺡ ﻋﻦ ﻭﺟﻮﺩ ﺃﻱ ﻣﻦ ﺍﻟﺤﺎﻻﺕ ﺍﺩﻧﺎﻩ ﺑﻮﺿﻊ ﺇﺷﺎﺭﺓ‬
"Below Undeclared Medical Case May Not Be Covered" No / ‫ﻻ‬ Yes / ‫ﻧﻌـﻢ‬ "‫"ﻟﻦ ﺗﺘﻢ ﺍﻟﺘﻐﻄﻴﺔ ﺍﻟﺘﺄﻣﻴﻨﻴﺔ ﻟﻠﺤﺎﻻﺕ ﺃﺩﻧﺎﻩ ﻓﻰ ﺣﺎﻝ ﻋﺪﻡ ﺍﻹﻓﺼﺎﺡ ﻋﻨﻬﺎ‬
Any hospital admission during last 12 months. ‫ ﺷﻬﺮ‬12 ‫ﻫﻞ ﺗﻢ ﺍﻟﺘﻨﻮﻳﻢ ﺑﺎﻟﻤﺴﺘﺸﻔﻰ ﺧﻼﻝ ﺃﺧﺮ‬
"Admission: registering as an admitted patient at the hospital until the following morning "
* * " ‫ ﺗﺴﺠﻴﻞ ﺍﻟﺸﺨﺺ ﺍﻟﻤﺆﻣﻦ ﻟﻪ ﻛﻤﺮﻳﺾ ﻣﻨﻮﻡ ﻓﻲ ﺍﻟﻤﺴﺘﺸﻔﻰ ﺣﺘﻰ ﺻﺒﺎﺡ ﺍﻟﻴﻮﻡ ﺍﻟﺘﺎﻟﻲ‬: ‫" ﺍﻟﺘﻨﻮﻳﻢ‬

Have you been diagnosed with any of the following chronic disease limited ‫ﻫﻞ ﺗﻢ ﺗﺸﺨﻴﺼﻚ ﺑﺄﻯ ﻣﻦ ﺍﻷﻣﺮﺍﺽ ﺍﻟﺘﺎﻟﻴﺔ ﻓﻘﻂ‬
to:Autism, listed Benign Tumor (Breast tumors, fibroid uterus, benign prostatic hyperplasia, ‫ﺃﻭﺭﺍﻡ ﺃﻭ‬,‫ﺗﻀﺨﻢ ﺍﻟﺒﺮﻭﺳﺘﺎﺗﺎ ﺍﻟﺤﻤﻴﺪ‬,‫ ﺃﻭﺭﺍﻡ ﺍﻟﺮﺣﻢ ﺍﻟﻠﻴﻔﻰ‬, ‫ﺍﻻﻭﺭﺍﻡ ﺍﻟﺤﻤﻴﺪﺓ ﺍﻟﺘﺎﻟﻴﺔ )ﺃﻭﺭﺍﻡ ﺍﻟﺜﺪﻯ‬,‫ﺍﻷﻭﺭﺍﻡ ﺍﻟﺴﺮﻃﺎﻧﻴﺔ‬,‫ﺍﻟﺘﻮﺣﺪ‬
thyroid goiter and parathyroid glands, live tumors, colon tumors). Malignant tumors, listed ‫ﺃﻣﺮﺍﺽ ﺍﻟﻘﻠﺐ ﺍﻟﺘﺎﻟﻴﺔ)ﺃﻣﺮﺍﺽ ﺷﺮﺍﻳﻴﻦ ﻭﺻﻤﺎﻣﺎﺕ ﺗﻀﺨﻢ ﺍﻟﻐﺪﺓ ﺍﻟﺪﺭﻗﻴﺔ‬, (‫ﺃﻭﺭﺍﻡ ﺍﻟﻘﻮﻟﻮﻥ‬, ‫ﻭﺃﻭﺭﺍﻡ ﺍﻻﻟﻜﺒﺪ‬,‫ﻭ ﺍﻟﺠﺎﺭ ﺍﻟﺪﺭﻗﻴﺔ‬
Cardiac diseases coronary and valve heart diseases, heart failure, cardiac fibrillation
myocardial infraction, heart clots). Chronic Hepatitis C. Gallstones Sever Kidney failure (stage
* * ‫ﺍﻻﻟﺘﻬﺎﺏ ﺍﻟﻜﺒﺪﻯ ﺍﻟﻔﻴﺮﻭﺳﻰ ﺍﻟﻤﺰﻣﻦ‬.( ‫ﺍﻟﺮﺟﻔﺎﻥ ﺍﻟﻘﻠﺒﻰ ﻭﺟﻠﻄﺎﺕ ﺍﻟﻘﻠﺐ‬, ‫ﻓﺸﻞ ﻋﻀﻠﺔ ﺍﻟﻘﻠﺐ‬, ‫ﺣﺼﻮﺍﺕ ﺍﻟﻤﺮﺍﺭﺓ ﺍﻟﻘﻠﺐ‬, ‫ﺝ ﻭﺳﻰ‬
,‫ ﺍﻟﺘﺮﺷﻴﺢ ﺍﻟﻜﻠﻮﻯ ﺃﻗﻞ ﻣﻦ‬,‫ ﺍﻟﻔﺸﻞ ﺍﻟﻜﻠﻮﻯﺍﻟﺸﺪﻳﺪ )ﺍﻟﻤﺮﺣﻠﺔ ﺍﻟﺨﺎﻣﺴﺔ ﻣﻦ ﺍﻣﺮﺍﺽ ﺍﻟﻜﻠﻰ ﺍﻟﺘﻰ ﺗﺴﺘﺪﻋﻰ ﺍﻟﻐﺴﻴﻞ ﺍﻟﻜﻠﻮﻯ‬15
5 Requiring dialysis, clearance of less tha 15 ml/ minute*). Urinary tract ‫ﻣﺮﺽ‬, ‫ﺩﻗﻴﻘﺔ(ﺣﺼﻮﺍﺕ ﺍﻟﻤﺴﺎﻟﻚ ﺍﻟﺒﻮﻟﻴﺔﺃﻣﺮﺍﺽ ﺍﻟﻤﻨﺎﻋﺔ ﺍﻟﺘﺎﻟﻴﺔ )ﺍﻟﺬﺋﺒﺔ ﺍﻟﺤﻤﺮﺍﺀﻭﺍﻟﺘﻬﺎﺏ ﺍﻟﻤﻔﺎﺻﻞ ﺍﻟﺮﻭﻣﺎﺗﻴﺰﻣﻴﺔﻭ ﺍﻟﺼﺪﻓﻴﺔ‬/‫ﻣﻞ‬
stones, hernias. Autoimmune disease (lupus, rheumatoid arthritis, psoriasis, Crohn's disease, ‫ﺍﻟﺘﻬﺎﺏ ﺍﻟﻘﻮﻟﻮﻥ ﺍﻟﺘﻘﺮﺣﻰ‬, ‫ﻛﺮﻭﻧﺰ‬,
ulcerative colitis,multiple sclerosis, celiac disease) ‫ﺣﺴﺎﺳﻴﺔ ﺍﻟﻘﻤﺢ‬, ‫ﺍﻟﺘﺼﻠﺐ ﺍﻟﻠﻮﻳﺤﻰ‬

Have you been diagnosed with any of the following congenital disorder or
hereditary diseases limited to: Cerebral palsy, Sickle cell disorder, Thalassemia, ‫ﻫﻞ ﺗﻢ ﺗﺸﺨﻴﺼﻚ ﺑﺄﻱ ﻣﻦ ﺍﻷﻣﺮﺍﺽ ﺍﻟﻮﺭﺍﺛﻴﺔ ﺃﻭ ﺍﻟﺘﺸﻮﻫﺎﺕ ﺍﻟﺨﻠﻘﻴﺔ ﺍﻟﺘﺎﻟﻴﺔ ﻓﻘﻂ‬
hemophilia, metabolic diseases, Hydrocephalus, spinal muscle atrophy, genital ‫ ﺿﻤﻮﺭ‬،‫ ﺃﺳﺘﺴﻘﺎﺀ ﺍﻟﺮﺃﺱ‬،‫ ﺃﻣﺮﺍﺽ ﺍﻟﺘﻤﺜﻴﻞ ﺍﻟﻐﺬﺍﺋﻲ‬،‫ ﺍﻟﻬﻴﻤﻮﻓﻴﻠﻴﺎ‬،‫ ﺍﻟﺘﻼﺳﻴﻤﻴﺎ‬،‫ﺍﺿﻄﺮﺍﺏ ﺍﻟﺨﻼﻳﺎ ﺍﻟﻤﻨﺠﻠﻴﺔ‬, ‫ﺍﻟﺸﻠﻞ ﺍﻟﺪﻣﺎﻏﻰ‬
malformations, chromosomal abnormalities. Gaucher's disease, G6PD Deficiency, cystic
fibrosis, hemochromatosis, Wilson disease. Polycystic Kidney Disease.
* * ‫ ﻣﺮﺽ ﺍﻟﺘﻜﺴﺮﺍﻟﻔﻮﻟﻰ‬،‫ ﻣﺮﺽ ﻏﻮﺷﺮ‬،‫ ﺃﻣﺮﺍﺽ ﺍﻟﻜﺮﻭﻣﻮﺳﻮﻣﺎﺕ‬،‫ ﺗﺸﻮﻫﺎﺕ ﺍﻷﻋﻀﺎﺀ ﺍﻟﺘﻨﺎﺳﻠﻴﺔ‬،‫ﺍﻟﻌﻀﻼﺕ ﺍﻟﺸﻮﻛﻲ‬
‫ﺗﻜﻴﺲ‬,‫ﻣﺮﺽ ﻭﻳﻠﺴﻮﻥ‬, (‫ ﻣﺮﺽ ﺗﻜﺪﺱ ﺍﻟﺤﺪﻳﺪ )ﻫﻴﻤﻮﻛﺮﻭﻣﺎﺗﻮﺳﻴﺲ‬،‫( ﺍﻟﺘﻠﻴﻒ ﺍﻟﻜﻴﺴﻲ ﻟﻠﺮﺋﺔ‬G6PD)
‫ﺍﻟﻜﻠﻴﺘﻴﻦ ﺍﻟﺨﻠﻔﻰ ﺍﻟﻮﺭﺍﺋﻰ‬

Have you been diagnosed with any of following eye diseases limited to: ،‫ ﻣﻴﺎﺓ ﺯﺭﻗﺎﺀ‬،‫ ﻣﻴﺎﺓ ﺑﻴﻀﺎﺀ‬:‫ﻫﻞ ﺗﻢ ﺗﺸﺨﻴﺼﻚ ﺑﺄﻱ ﻣﻦ ﺃﻣﺮﺍﺽ ﺍﻟﻌﻴﻦ ﺍﻟﺘﺎﻟﻴﺔ ﻓﻘﻂ‬
Cataract, Glaucoma, Retinal diseases. * * ‫ﺃﻣﺮﺍﺽ ﺍﻟﺸﺒﻜﻴﺔ‬
Have you been diagnosed with any of the following bone diseases limited ‫ ﺍﻹﻧﺰﻻﻕ ﺍﻟﻐﻀﺮﻭﻓﻲ‬:‫ﻫﻞ ﺗﻢ ﺗﺸﺨﻴﺼﻚ ﺑﺄﻱ ﻣﻦ ﺃﻣﺮﺍﺽ ﺍﻟﻌﻈﺎﻡ ﺍﻟﺘﺎﻟﻴﺔ ﻓﻘﻂ‬
to:Vertebral disc prolapse (moderate or severe), Scoliosis (moderate or severe)**, or ligament
tears, osteoarthritis (moderate or severe )
* * ‫ﺗﻤﺰﻕ ﺍﻷﺭﺑﻄﺔ‬،‫ﺍﻟﺘﻬﺎﺏ ﺍﻟﻤﻔﺎﺻﻞ‬،‫ﺇﻧﺤﺮﺍﻑ ﺍﻟﻌﻤﻮﺩ ﺍﻟﻔﻘﺮﻱ‬,‫ﺍﻟﺪﻳﺴﻚ‬

Pregnant Female Only ‫ﻟﻸﻧﺜﻰ ﺍﻟﺤﺎﻣﻞ ﻓﻘﻂ‬

‫ﺣﻤﻞ ﺣﺎﻟﻲ ﺟﻨﻴﻦ ﻭﺍﺣﺪ‬
Current Single Pregnancy
* *
‫ﺣﻤﻞ ﺣﺎﻟﻲ ﻣﻊ ﻗﻴﺼﺮﻳﺔ ﺳﺎﺑﻘﺔ‬
Current Single Pregnancy with Previous CS Delivery
* *
‫ﺣﻤﻞ ﺣﺎﻟﻲ ﻣﺘﻌﺪﺩ ﺍﻷﺟﻨﺔ‬
Current Multiple Pregnancy
* *
Expected delivery date .. / .. / .... ‫ﺗﺎﺭﻳﺦ ﺍﻟﻮﻻﺩﺓ ﺍﻟﻤﺘﻮﻗﻊ‬
Employee and dependents details that need to be added ‫ﺑﻴﺎﻧﺎﺕ ﺍﻟﻤﻮﻇﻒ ﻭﺃﻓﺮﺍﺩ ﺍﻟﻌﺎﺋﻠﺔ ﺍﻟﻤﺮﺍﺩ ﺇﺿﺎﻓﺘﻬﻢ‬
In case of a yes answer above, please declare the case in the table below ‫ ﺍﻟﺮﺟﺎﺀ ﺫﻛﺮ ﺍﻟﺤﺎﻟﺔ ﻓﻲ ﺍﻟﺠﺪﻭﻝ ﺃﺩﻧﺎﻩ‬،‫ﻓﻲ ﺣﺎﻟﺔ ﺍﻹﺟﺎﺑﺔ ﺑﻨﻌﻢ ﺃﻋﻼﻩ‬
‫ﺇﺳﻢ ﻣﻘﺪﻡ ﺍﻟﺨﺪﻣﺔ‬ ‫ﺍﻟﺤﺎﻟﺔ‬ ‫ﺭﻗﻢ ﺍﻟﺠﻮﺍﻝ‬ ‫ﺍﻟﻄﻮﻝ‬ ‫ﺍﻟﻮﺯﻥ‬ ‫ﺭﻗﻢ ﺍﻟﻬﻮﻳﺔ‬ ‫ﺍﻟﻘﺮﺍﺑﺔ‬ ‫ﺍﻟﺠﻨﺲ‬ ‫ ﺃﻓﺮﺍﺩ ﺍﻟﻌﺎﺋﻠﺔ‬/ ‫ﺍﺳﻢ ﺍﻟﻤﻮﻇﻒ‬ ‫ﻡ‬
2260293580 Spouse Female / ‫ ﺃﻧﺜﻰ‬Zainab Parween - - Mohammad 1
2
3
4
5
Undertakings : ‫ﺍﻹﻗﺮﺍﺭ ﻭﺍﻟﺘﻔﻮﻳﺾ‬
1- I hereby undertake that all the above information is correct and the acceptance of my ‫ﻭﺍﻟﻤﻌﻠﻮﻣﺎﺕ ﺍﻟﻤﺬﻛﻮﺭﺓ ﺃﻋﻼﻩ ﻛﺎﻣﻠﺔ ﻭﺻﺤﻴﺤﺔ ﻭﺑﻨﺎﺀ ﻋﻠﻴﻪ ﻓﺈﻥ ﻗﺒﻮﻝ ﺍﻟﻄﻠﺐ ﺳﻴﺘﻢ‬: ‫ ﺃﻗﺮ ﺃﻥ ﺍﻟﺒﻴﺎﻧﺎﺕ‬-1
enrollment will be on the basis of such information and that Malath Cooperative Insurance ‫ﻋﻠﻰ ﺃﺳﺎﺱ ﻫﺬﻩ ﺍﻟﺒﻴﺎﻧﺎﺕ ﻭﺃﻥ ﺷﺮﻛﺔ ﻣﻼﺫ ﻟﻠﺘﺄﻣﻴﻦ ﺍﻟﺘﻌﺎﻭﻧﻲ ﻟﻬﺎ ﺍﻟﺤﻖ ﻓﻲ ﺍﻻﺗﺼﺎﻝ ﺑﺎﻟﻤﺴﺘﺸﻔﻴﺎﺕ ﺍﻟﺘﻲ‬
Company has the right to contact the hospital(s) I deal with to collect any ‫ﺃﺗﻌﺎﻣﻞ ﻣﻌﻬﺎ ﻟﺘﺰﻭﻳﺪﻫﺎ ﺑﺄﻱ ﻣﻌﻠﻮﻣﺎﺕ ﻃﺒﻴﺔ ﻗﺪ ﺗﺤﺘﺎﺝ ﺇﻟﻴﻬﺎ ﻟﺘﻘﻴﻴﻢ ﺍﻟﻤﺨﺎﻃﺮ‬
medical information needed to assess the risk(s).

2- I agree that Malath Cooperative Insurance Company has the right to reject the ‫ ﺃﻭﺍﻓﻖ ﻋﻠﻰ ﺃﺣﻘﻴﺔ ﺷﺮﻛﺔ ﻣﻼﺫ ﻟﻠﺘﺄﻣﻴﻦ ﻓﻲ ﺭﻓﺾ ﺍﻟﻤﻄﺎﻟﺒﺔ ﺃﻭ ﺍﻟﺘﻐﻄﻴﺔ ﻛﻠﻴﺎ ﻋﻨﺪ ﻋﺪﻡ ﺍﻹﻓﺼﺎﺡ ﻋﻦ ﻭﺟﻮﺩ ﺃﻱ ﻣﻦ ﺍﻟﺤﺎﻻﺕ‬-2
coverage/claims in full in case of no declaration of any cases prior to the contractual date or ‫ﺍﻟﻤﺬﻛﻮﺭﺓ ﺃﻋﻼﻩ ﺍﻟﺘﻲ ﻧﺸﺄﺕ ﻗﺒﻞ ﺗﺎﺭﻳﺦ ﺍﻟﺘﻌﺎﻗﺪ ﺃﻭ ﻗﺒﻞ ﺗﺴﺠﻴﻞ ﺃﻭ ﺇﺿﺎﻓﺔ ﻋﻀﻮ ﺧﻼﻝ ﻓﺘﺮﺓ ﺳﺮﻳﺎﻥ ﺍﻟﻌﻘﺪ‬
before enrolling or adding a new member during the contract.

3- I hereby confirm reading and understanding all points presented in this form and I agree that ‫ ﺃﻗﺮﺑﺄﻧﻲ ﻗﺪ ﻗﺮﺃﺕ ﻭﻓﻬﻤﺖ ﺟﻤﻴﻊ ﻣﺎ ﺟﺎﺀ ﻓﻲ ﻫﺬﺍ ﺍﻟﻨﻤﻮﺫﺝ ﻛﻤﺎ ﺃﺗﻌﻬﺪ ﺑﺄﻥ ﻋﺪﻡ ﺇﺷﺎﺭﺗﻲ ﺃﻣﺎﻡ ﺃﻱ ﻣﻦ‬-3
not marking any case is understood as “Nothing requires declaration” and I sign on these ‫ﺍﻟﺤﺎﻻﺕ ﺍﻟﻤﺬﻛﻮﺭﺓ ﺃﻋﻼﻩ ﻳﻌﺘﺒﺮ ﺑﻤﺜﺎﺑﺔ ﻧﻔﻲ ﻭﺟﻮﺩ ﻣﺎﻳﺴﺘﺤﻖ ﺍﻹﻓﺼﺎﺡ ﻋﻨﻪ ﻭﻋﻠﻴﻪ ﺃﻭﻗﻊ‬
basis.
4- Failure to fill the weight and height information will result in refusal to cover
the cost of obesity surgery. ‫ ﻋﺪﻡ ﺗﻌﺒﺌﺔ ﺑﻴﺎﻧﺎﺕ ﺍﻟﻄﻮﻝ ﻭﺍﻟﻮﺯﻥ ﺳﻴﺆﺩﻱ ﺇﻟﻰ ﺭﻓﺾ ﺗﻐﻄﻴﺔ ﺗﻜﺎﻟﻴﻒ ﻋﻤﻠﻴﺔ ﺟﺮﺍﺣﺔ ﺍﻟﺴﻤﻨﺔ ﺍﻟﻤﻔﺮﻃﺔ‬-4

Entity's stamp ‫ﺧﺘﻢ ﺟﻬﺔ ﺍﻟﻌﻤﻞ‬ Insured Signature ‫ﺗﻮﻗﻴﻊ ﺍﻟﻤﻮﻇﻒ‬ Date ‫ﺍﻟﺘﺎﺭﻳﺦ‬
.. / .. / ....

New_Health_Insurance.rdf Page 11 of 39 V.20 13-DEC-2023 01:30 PM

 ‫ﻧﻤﻮﺫﺝ ﺍﻻﻓﺼﺎﺡ ﺍﻟﻄﺒﻲ ﺍﻟﻤﻮﺣﺪ‬
Unified Medical Declaration Form
Product Code: A-MLTH-2-C-08-014
Dear Insured: ‫ﻋﺰﻳﺰﻱ ﺍﻟﻤﺆﻣﻦ ﻟﻪ‬
Please Fill out the form correctly for the purpose of pricing and to ensured that you and your ‫ﻧﺄﻣﻞ ﻗﻴﺎﻣﻚ ﺑﺘﻌﺒﺌﺔ ﻫﺬﺍ ﺍﻟﻨﻤﻮﺫﺝ ﺑﺎﻟﺸﻜﻞ ﺍﻟﺼﺤﻴﺢ ﻟﻐﺮﺽ ﺍﻟﺘﺴﻌﻴﺮ ﻭﻟﻀﻤﺎﻥ ﺣﺼﻮﻟﻚ ﻭﺃﻓﺮﺍﺩ ﺃﺳﺮﺗﻚ ﻋﻠﻰ ﺧﺪﻣﺎﺕ‬
family receive health care services as required according to your unfied policy benefit ‫ﺍﻟﺮﻋﺎﻳﺔ ﺍﻟﺼﺤﻴﺔ ﺑﺎﻟﺸﻜﻞ ﺍﻟﻤﻄﻠﻮﺏ ﺣﺴﺐ ﻣﻨﺎﻓﻊ ﺍﻟﻮﺛﻴﻘﺔ ﺍﻟﻤﻮﺣﺪﺓ‬

Addition ‫ﺇﺿﺎﻓﺔ‬ New ‫ﺟﺪﻳﺪ‬ Type ‫ﻧﻮﻉ ﺍﻟﻄﻠﺐ‬

CR No 7011507360 ‫ﺍﻟﺴﺠﻞ ﺍﻟﺘﺠﺎﺭﻱ‬ Entity Name HADDAJ AL HIJAZ EST ‫ﺃﺳﻢ ﺍﻟﻤﻨﺸﺄﺓ‬
Mobile No 0509300773 ‫ﺭﻗﻢ ﺍﻟﺠﻮﺍﻝ‬ Salman Mohammed Siddiqui ‫ﺍﺳﻢ ﺍﻟﻤﻮﻇﻒ‬
ID Number 2 2 6 0 2 9 3 5 1 5 ‫ﺭﻗﻢ ﺍﻟﻬﻮﻳﺔ‬
Male / ‫ﺫﻛﺮ‬ India
Gender ‫ ﺍﻟﺠﻨﺲ‬Nationality ‫ ﺍﻟﺠﻨﺴﻴﺔ‬Marital status Married * ‫ﻣﺘﺰﻭﺝ‬ Single R ‫ﺃﻋﺰﺏ‬ ‫ﺍﻟﺤﺎﻟﺔ ﺍﻻﺟﺘﻤﺎﻋﻴﺔ‬
Please declare any of the below cases by marking P under the word Yes ‫ ﻓﻲ ﺍﻟﻤﺮﺑﻊ ﺗﺤﺖ ﻛﻠﻤﺔ ﻧﻌﻢ‬P ‫ﻳﺮﺟﻰ ﺍﻹﻓﺼﺎﺡ ﻋﻦ ﻭﺟﻮﺩ ﺃﻱ ﻣﻦ ﺍﻟﺤﺎﻻﺕ ﺍﺩﻧﺎﻩ ﺑﻮﺿﻊ ﺇﺷﺎﺭﺓ‬
"Below Undeclared Medical Case May Not Be Covered" No / ‫ﻻ‬ Yes / ‫ﻧﻌـﻢ‬ "‫"ﻟﻦ ﺗﺘﻢ ﺍﻟﺘﻐﻄﻴﺔ ﺍﻟﺘﺄﻣﻴﻨﻴﺔ ﻟﻠﺤﺎﻻﺕ ﺃﺩﻧﺎﻩ ﻓﻰ ﺣﺎﻝ ﻋﺪﻡ ﺍﻹﻓﺼﺎﺡ ﻋﻨﻬﺎ‬
Any hospital admission during last 12 months. ‫ ﺷﻬﺮ‬12 ‫ﻫﻞ ﺗﻢ ﺍﻟﺘﻨﻮﻳﻢ ﺑﺎﻟﻤﺴﺘﺸﻔﻰ ﺧﻼﻝ ﺃﺧﺮ‬
"Admission: registering as an admitted patient at the hospital until the following morning "
* * " ‫ ﺗﺴﺠﻴﻞ ﺍﻟﺸﺨﺺ ﺍﻟﻤﺆﻣﻦ ﻟﻪ ﻛﻤﺮﻳﺾ ﻣﻨﻮﻡ ﻓﻲ ﺍﻟﻤﺴﺘﺸﻔﻰ ﺣﺘﻰ ﺻﺒﺎﺡ ﺍﻟﻴﻮﻡ ﺍﻟﺘﺎﻟﻲ‬: ‫" ﺍﻟﺘﻨﻮﻳﻢ‬

Have you been diagnosed with any of the following chronic disease limited ‫ﻫﻞ ﺗﻢ ﺗﺸﺨﻴﺼﻚ ﺑﺄﻯ ﻣﻦ ﺍﻷﻣﺮﺍﺽ ﺍﻟﺘﺎﻟﻴﺔ ﻓﻘﻂ‬
to:Autism, listed Benign Tumor (Breast tumors, fibroid uterus, benign prostatic hyperplasia, ‫ﺃﻭﺭﺍﻡ ﺃﻭ‬,‫ﺗﻀﺨﻢ ﺍﻟﺒﺮﻭﺳﺘﺎﺗﺎ ﺍﻟﺤﻤﻴﺪ‬,‫ ﺃﻭﺭﺍﻡ ﺍﻟﺮﺣﻢ ﺍﻟﻠﻴﻔﻰ‬, ‫ﺍﻻﻭﺭﺍﻡ ﺍﻟﺤﻤﻴﺪﺓ ﺍﻟﺘﺎﻟﻴﺔ )ﺃﻭﺭﺍﻡ ﺍﻟﺜﺪﻯ‬,‫ﺍﻷﻭﺭﺍﻡ ﺍﻟﺴﺮﻃﺎﻧﻴﺔ‬,‫ﺍﻟﺘﻮﺣﺪ‬
thyroid goiter and parathyroid glands, live tumors, colon tumors). Malignant tumors, listed ‫ﺃﻣﺮﺍﺽ ﺍﻟﻘﻠﺐ ﺍﻟﺘﺎﻟﻴﺔ)ﺃﻣﺮﺍﺽ ﺷﺮﺍﻳﻴﻦ ﻭﺻﻤﺎﻣﺎﺕ ﺗﻀﺨﻢ ﺍﻟﻐﺪﺓ ﺍﻟﺪﺭﻗﻴﺔ‬, (‫ﺃﻭﺭﺍﻡ ﺍﻟﻘﻮﻟﻮﻥ‬, ‫ﻭﺃﻭﺭﺍﻡ ﺍﻻﻟﻜﺒﺪ‬,‫ﻭ ﺍﻟﺠﺎﺭ ﺍﻟﺪﺭﻗﻴﺔ‬
Cardiac diseases coronary and valve heart diseases, heart failure, cardiac fibrillation
myocardial infraction, heart clots). Chronic Hepatitis C. Gallstones Sever Kidney failure (stage
* * ‫ﺍﻻﻟﺘﻬﺎﺏ ﺍﻟﻜﺒﺪﻯ ﺍﻟﻔﻴﺮﻭﺳﻰ ﺍﻟﻤﺰﻣﻦ‬.( ‫ﺍﻟﺮﺟﻔﺎﻥ ﺍﻟﻘﻠﺒﻰ ﻭﺟﻠﻄﺎﺕ ﺍﻟﻘﻠﺐ‬, ‫ﻓﺸﻞ ﻋﻀﻠﺔ ﺍﻟﻘﻠﺐ‬, ‫ﺣﺼﻮﺍﺕ ﺍﻟﻤﺮﺍﺭﺓ ﺍﻟﻘﻠﺐ‬, ‫ﺝ ﻭﺳﻰ‬
,‫ ﺍﻟﺘﺮﺷﻴﺢ ﺍﻟﻜﻠﻮﻯ ﺃﻗﻞ ﻣﻦ‬,‫ ﺍﻟﻔﺸﻞ ﺍﻟﻜﻠﻮﻯﺍﻟﺸﺪﻳﺪ )ﺍﻟﻤﺮﺣﻠﺔ ﺍﻟﺨﺎﻣﺴﺔ ﻣﻦ ﺍﻣﺮﺍﺽ ﺍﻟﻜﻠﻰ ﺍﻟﺘﻰ ﺗﺴﺘﺪﻋﻰ ﺍﻟﻐﺴﻴﻞ ﺍﻟﻜﻠﻮﻯ‬15
5 Requiring dialysis, clearance of less tha 15 ml/ minute*). Urinary tract ‫ﻣﺮﺽ‬, ‫ﺩﻗﻴﻘﺔ(ﺣﺼﻮﺍﺕ ﺍﻟﻤﺴﺎﻟﻚ ﺍﻟﺒﻮﻟﻴﺔﺃﻣﺮﺍﺽ ﺍﻟﻤﻨﺎﻋﺔ ﺍﻟﺘﺎﻟﻴﺔ )ﺍﻟﺬﺋﺒﺔ ﺍﻟﺤﻤﺮﺍﺀﻭﺍﻟﺘﻬﺎﺏ ﺍﻟﻤﻔﺎﺻﻞ ﺍﻟﺮﻭﻣﺎﺗﻴﺰﻣﻴﺔﻭ ﺍﻟﺼﺪﻓﻴﺔ‬/‫ﻣﻞ‬
stones, hernias. Autoimmune disease (lupus, rheumatoid arthritis, psoriasis, Crohn's disease, ‫ﺍﻟﺘﻬﺎﺏ ﺍﻟﻘﻮﻟﻮﻥ ﺍﻟﺘﻘﺮﺣﻰ‬, ‫ﻛﺮﻭﻧﺰ‬,
ulcerative colitis,multiple sclerosis, celiac disease) ‫ﺣﺴﺎﺳﻴﺔ ﺍﻟﻘﻤﺢ‬, ‫ﺍﻟﺘﺼﻠﺐ ﺍﻟﻠﻮﻳﺤﻰ‬

Have you been diagnosed with any of the following congenital disorder or
hereditary diseases limited to: Cerebral palsy, Sickle cell disorder, Thalassemia, ‫ﻫﻞ ﺗﻢ ﺗﺸﺨﻴﺼﻚ ﺑﺄﻱ ﻣﻦ ﺍﻷﻣﺮﺍﺽ ﺍﻟﻮﺭﺍﺛﻴﺔ ﺃﻭ ﺍﻟﺘﺸﻮﻫﺎﺕ ﺍﻟﺨﻠﻘﻴﺔ ﺍﻟﺘﺎﻟﻴﺔ ﻓﻘﻂ‬
hemophilia, metabolic diseases, Hydrocephalus, spinal muscle atrophy, genital ‫ ﺿﻤﻮﺭ‬،‫ ﺃﺳﺘﺴﻘﺎﺀ ﺍﻟﺮﺃﺱ‬،‫ ﺃﻣﺮﺍﺽ ﺍﻟﺘﻤﺜﻴﻞ ﺍﻟﻐﺬﺍﺋﻲ‬،‫ ﺍﻟﻬﻴﻤﻮﻓﻴﻠﻴﺎ‬،‫ ﺍﻟﺘﻼﺳﻴﻤﻴﺎ‬،‫ﺍﺿﻄﺮﺍﺏ ﺍﻟﺨﻼﻳﺎ ﺍﻟﻤﻨﺠﻠﻴﺔ‬, ‫ﺍﻟﺸﻠﻞ ﺍﻟﺪﻣﺎﻏﻰ‬
malformations, chromosomal abnormalities. Gaucher's disease, G6PD Deficiency, cystic
fibrosis, hemochromatosis, Wilson disease. Polycystic Kidney Disease.
* * ‫ ﻣﺮﺽ ﺍﻟﺘﻜﺴﺮﺍﻟﻔﻮﻟﻰ‬،‫ ﻣﺮﺽ ﻏﻮﺷﺮ‬،‫ ﺃﻣﺮﺍﺽ ﺍﻟﻜﺮﻭﻣﻮﺳﻮﻣﺎﺕ‬،‫ ﺗﺸﻮﻫﺎﺕ ﺍﻷﻋﻀﺎﺀ ﺍﻟﺘﻨﺎﺳﻠﻴﺔ‬،‫ﺍﻟﻌﻀﻼﺕ ﺍﻟﺸﻮﻛﻲ‬
‫ﺗﻜﻴﺲ‬,‫ﻣﺮﺽ ﻭﻳﻠﺴﻮﻥ‬, (‫ ﻣﺮﺽ ﺗﻜﺪﺱ ﺍﻟﺤﺪﻳﺪ )ﻫﻴﻤﻮﻛﺮﻭﻣﺎﺗﻮﺳﻴﺲ‬،‫( ﺍﻟﺘﻠﻴﻒ ﺍﻟﻜﻴﺴﻲ ﻟﻠﺮﺋﺔ‬G6PD)
‫ﺍﻟﻜﻠﻴﺘﻴﻦ ﺍﻟﺨﻠﻔﻰ ﺍﻟﻮﺭﺍﺋﻰ‬

Have you been diagnosed with any of following eye diseases limited to: ،‫ ﻣﻴﺎﺓ ﺯﺭﻗﺎﺀ‬،‫ ﻣﻴﺎﺓ ﺑﻴﻀﺎﺀ‬:‫ﻫﻞ ﺗﻢ ﺗﺸﺨﻴﺼﻚ ﺑﺄﻱ ﻣﻦ ﺃﻣﺮﺍﺽ ﺍﻟﻌﻴﻦ ﺍﻟﺘﺎﻟﻴﺔ ﻓﻘﻂ‬
Cataract, Glaucoma, Retinal diseases. * * ‫ﺃﻣﺮﺍﺽ ﺍﻟﺸﺒﻜﻴﺔ‬
Have you been diagnosed with any of the following bone diseases limited ‫ ﺍﻹﻧﺰﻻﻕ ﺍﻟﻐﻀﺮﻭﻓﻲ‬:‫ﻫﻞ ﺗﻢ ﺗﺸﺨﻴﺼﻚ ﺑﺄﻱ ﻣﻦ ﺃﻣﺮﺍﺽ ﺍﻟﻌﻈﺎﻡ ﺍﻟﺘﺎﻟﻴﺔ ﻓﻘﻂ‬
to:Vertebral disc prolapse (moderate or severe), Scoliosis (moderate or severe)**, or ligament
tears, osteoarthritis (moderate or severe )
* * ‫ﺗﻤﺰﻕ ﺍﻷﺭﺑﻄﺔ‬،‫ﺍﻟﺘﻬﺎﺏ ﺍﻟﻤﻔﺎﺻﻞ‬،‫ﺇﻧﺤﺮﺍﻑ ﺍﻟﻌﻤﻮﺩ ﺍﻟﻔﻘﺮﻱ‬,‫ﺍﻟﺪﻳﺴﻚ‬

Pregnant Female Only ‫ﻟﻸﻧﺜﻰ ﺍﻟﺤﺎﻣﻞ ﻓﻘﻂ‬

‫ﺣﻤﻞ ﺣﺎﻟﻲ ﺟﻨﻴﻦ ﻭﺍﺣﺪ‬
Current Single Pregnancy
* *
‫ﺣﻤﻞ ﺣﺎﻟﻲ ﻣﻊ ﻗﻴﺼﺮﻳﺔ ﺳﺎﺑﻘﺔ‬
Current Single Pregnancy with Previous CS Delivery
* *
‫ﺣﻤﻞ ﺣﺎﻟﻲ ﻣﺘﻌﺪﺩ ﺍﻷﺟﻨﺔ‬
Current Multiple Pregnancy
* *
Expected delivery date .. / .. / .... ‫ﺗﺎﺭﻳﺦ ﺍﻟﻮﻻﺩﺓ ﺍﻟﻤﺘﻮﻗﻊ‬
Employee and dependents details that need to be added ‫ﺑﻴﺎﻧﺎﺕ ﺍﻟﻤﻮﻇﻒ ﻭﺃﻓﺮﺍﺩ ﺍﻟﻌﺎﺋﻠﺔ ﺍﻟﻤﺮﺍﺩ ﺇﺿﺎﻓﺘﻬﻢ‬
In case of a yes answer above, please declare the case in the table below ‫ ﺍﻟﺮﺟﺎﺀ ﺫﻛﺮ ﺍﻟﺤﺎﻟﺔ ﻓﻲ ﺍﻟﺠﺪﻭﻝ ﺃﺩﻧﺎﻩ‬،‫ﻓﻲ ﺣﺎﻟﺔ ﺍﻹﺟﺎﺑﺔ ﺑﻨﻌﻢ ﺃﻋﻼﻩ‬
‫ﺇﺳﻢ ﻣﻘﺪﻡ ﺍﻟﺨﺪﻣﺔ‬ ‫ﺍﻟﺤﺎﻟﺔ‬ ‫ﺭﻗﻢ ﺍﻟﺠﻮﺍﻝ‬ ‫ﺍﻟﻄﻮﻝ‬ ‫ﺍﻟﻮﺯﻥ‬ ‫ﺭﻗﻢ ﺍﻟﻬﻮﻳﺔ‬ ‫ﺍﻟﻘﺮﺍﺑﺔ‬ ‫ﺍﻟﺠﻨﺲ‬ ‫ ﺃﻓﺮﺍﺩ ﺍﻟﻌﺎﺋﻠﺔ‬/ ‫ﺍﺳﻢ ﺍﻟﻤﻮﻇﻒ‬ ‫ﻡ‬
2260293515 Child Male / ‫ ﺫﻛﺮ‬Salman Mohammed Siddiqui 1
2
3
4
5
Undertakings : ‫ﺍﻹﻗﺮﺍﺭ ﻭﺍﻟﺘﻔﻮﻳﺾ‬
1- I hereby undertake that all the above information is correct and the acceptance of my ‫ﻭﺍﻟﻤﻌﻠﻮﻣﺎﺕ ﺍﻟﻤﺬﻛﻮﺭﺓ ﺃﻋﻼﻩ ﻛﺎﻣﻠﺔ ﻭﺻﺤﻴﺤﺔ ﻭﺑﻨﺎﺀ ﻋﻠﻴﻪ ﻓﺈﻥ ﻗﺒﻮﻝ ﺍﻟﻄﻠﺐ ﺳﻴﺘﻢ‬: ‫ ﺃﻗﺮ ﺃﻥ ﺍﻟﺒﻴﺎﻧﺎﺕ‬-1
enrollment will be on the basis of such information and that Malath Cooperative Insurance ‫ﻋﻠﻰ ﺃﺳﺎﺱ ﻫﺬﻩ ﺍﻟﺒﻴﺎﻧﺎﺕ ﻭﺃﻥ ﺷﺮﻛﺔ ﻣﻼﺫ ﻟﻠﺘﺄﻣﻴﻦ ﺍﻟﺘﻌﺎﻭﻧﻲ ﻟﻬﺎ ﺍﻟﺤﻖ ﻓﻲ ﺍﻻﺗﺼﺎﻝ ﺑﺎﻟﻤﺴﺘﺸﻔﻴﺎﺕ ﺍﻟﺘﻲ‬
Company has the right to contact the hospital(s) I deal with to collect any ‫ﺃﺗﻌﺎﻣﻞ ﻣﻌﻬﺎ ﻟﺘﺰﻭﻳﺪﻫﺎ ﺑﺄﻱ ﻣﻌﻠﻮﻣﺎﺕ ﻃﺒﻴﺔ ﻗﺪ ﺗﺤﺘﺎﺝ ﺇﻟﻴﻬﺎ ﻟﺘﻘﻴﻴﻢ ﺍﻟﻤﺨﺎﻃﺮ‬
medical information needed to assess the risk(s).

2- I agree that Malath Cooperative Insurance Company has the right to reject the ‫ ﺃﻭﺍﻓﻖ ﻋﻠﻰ ﺃﺣﻘﻴﺔ ﺷﺮﻛﺔ ﻣﻼﺫ ﻟﻠﺘﺄﻣﻴﻦ ﻓﻲ ﺭﻓﺾ ﺍﻟﻤﻄﺎﻟﺒﺔ ﺃﻭ ﺍﻟﺘﻐﻄﻴﺔ ﻛﻠﻴﺎ ﻋﻨﺪ ﻋﺪﻡ ﺍﻹﻓﺼﺎﺡ ﻋﻦ ﻭﺟﻮﺩ ﺃﻱ ﻣﻦ ﺍﻟﺤﺎﻻﺕ‬-2
coverage/claims in full in case of no declaration of any cases prior to the contractual date or ‫ﺍﻟﻤﺬﻛﻮﺭﺓ ﺃﻋﻼﻩ ﺍﻟﺘﻲ ﻧﺸﺄﺕ ﻗﺒﻞ ﺗﺎﺭﻳﺦ ﺍﻟﺘﻌﺎﻗﺪ ﺃﻭ ﻗﺒﻞ ﺗﺴﺠﻴﻞ ﺃﻭ ﺇﺿﺎﻓﺔ ﻋﻀﻮ ﺧﻼﻝ ﻓﺘﺮﺓ ﺳﺮﻳﺎﻥ ﺍﻟﻌﻘﺪ‬
before enrolling or adding a new member during the contract.

3- I hereby confirm reading and understanding all points presented in this form and I agree that ‫ ﺃﻗﺮﺑﺄﻧﻲ ﻗﺪ ﻗﺮﺃﺕ ﻭﻓﻬﻤﺖ ﺟﻤﻴﻊ ﻣﺎ ﺟﺎﺀ ﻓﻲ ﻫﺬﺍ ﺍﻟﻨﻤﻮﺫﺝ ﻛﻤﺎ ﺃﺗﻌﻬﺪ ﺑﺄﻥ ﻋﺪﻡ ﺇﺷﺎﺭﺗﻲ ﺃﻣﺎﻡ ﺃﻱ ﻣﻦ‬-3
not marking any case is understood as “Nothing requires declaration” and I sign on these ‫ﺍﻟﺤﺎﻻﺕ ﺍﻟﻤﺬﻛﻮﺭﺓ ﺃﻋﻼﻩ ﻳﻌﺘﺒﺮ ﺑﻤﺜﺎﺑﺔ ﻧﻔﻲ ﻭﺟﻮﺩ ﻣﺎﻳﺴﺘﺤﻖ ﺍﻹﻓﺼﺎﺡ ﻋﻨﻪ ﻭﻋﻠﻴﻪ ﺃﻭﻗﻊ‬
basis.
4- Failure to fill the weight and height information will result in refusal to cover
the cost of obesity surgery. ‫ ﻋﺪﻡ ﺗﻌﺒﺌﺔ ﺑﻴﺎﻧﺎﺕ ﺍﻟﻄﻮﻝ ﻭﺍﻟﻮﺯﻥ ﺳﻴﺆﺩﻱ ﺇﻟﻰ ﺭﻓﺾ ﺗﻐﻄﻴﺔ ﺗﻜﺎﻟﻴﻒ ﻋﻤﻠﻴﺔ ﺟﺮﺍﺣﺔ ﺍﻟﺴﻤﻨﺔ ﺍﻟﻤﻔﺮﻃﺔ‬-4

Entity's stamp ‫ﺧﺘﻢ ﺟﻬﺔ ﺍﻟﻌﻤﻞ‬ Insured Signature ‫ﺗﻮﻗﻴﻊ ﺍﻟﻤﻮﻇﻒ‬ Date ‫ﺍﻟﺘﺎﺭﻳﺦ‬
.. / .. / ....

New_Health_Insurance.rdf Page 12 of 39 V.20 13-DEC-2023 01:30 PM

 ‫ﻧﻤﻮﺫﺝ ﺍﻻﻓﺼﺎﺡ ﺍﻟﻄﺒﻲ ﺍﻟﻤﻮﺣﺪ‬
Unified Medical Declaration Form
Product Code: A-MLTH-2-C-08-014
Dear Insured: ‫ﻋﺰﻳﺰﻱ ﺍﻟﻤﺆﻣﻦ ﻟﻪ‬
Please Fill out the form correctly for the purpose of pricing and to ensured that you and your ‫ﻧﺄﻣﻞ ﻗﻴﺎﻣﻚ ﺑﺘﻌﺒﺌﺔ ﻫﺬﺍ ﺍﻟﻨﻤﻮﺫﺝ ﺑﺎﻟﺸﻜﻞ ﺍﻟﺼﺤﻴﺢ ﻟﻐﺮﺽ ﺍﻟﺘﺴﻌﻴﺮ ﻭﻟﻀﻤﺎﻥ ﺣﺼﻮﻟﻚ ﻭﺃﻓﺮﺍﺩ ﺃﺳﺮﺗﻚ ﻋﻠﻰ ﺧﺪﻣﺎﺕ‬
family receive health care services as required according to your unfied policy benefit ‫ﺍﻟﺮﻋﺎﻳﺔ ﺍﻟﺼﺤﻴﺔ ﺑﺎﻟﺸﻜﻞ ﺍﻟﻤﻄﻠﻮﺏ ﺣﺴﺐ ﻣﻨﺎﻓﻊ ﺍﻟﻮﺛﻴﻘﺔ ﺍﻟﻤﻮﺣﺪﺓ‬

Addition ‫ﺇﺿﺎﻓﺔ‬ New ‫ﺟﺪﻳﺪ‬ Type ‫ﻧﻮﻉ ﺍﻟﻄﻠﺐ‬

CR No 7011507360 ‫ﺍﻟﺴﺠﻞ ﺍﻟﺘﺠﺎﺭﻱ‬ Entity Name HADDAJ AL HIJAZ EST ‫ﺃﺳﻢ ﺍﻟﻤﻨﺸﺄﺓ‬
Mobile No 0509300773 ‫ﺭﻗﻢ ﺍﻟﺠﻮﺍﻝ‬ Abeer Mohammed Al Siddique ‫ﺍﺳﻢ ﺍﻟﻤﻮﻇﻒ‬
ID Number 2 2 8 5 6 3 9 2 8 8 ‫ﺭﻗﻢ ﺍﻟﻬﻮﻳﺔ‬
Gender Female / ‫ﺍﻟﺠﻨﺲ ﺃﻧﺜﻰ‬ Nationality India ‫ ﺍﻟﺠﻨﺴﻴﺔ‬Marital status Married * ‫ﻣﺘﺰﻭﺝ‬ Single R ‫ﺃﻋﺰﺏ‬ ‫ﺍﻟﺤﺎﻟﺔ ﺍﻻﺟﺘﻤﺎﻋﻴﺔ‬
Please declare any of the below cases by marking P under the word Yes ‫ ﻓﻲ ﺍﻟﻤﺮﺑﻊ ﺗﺤﺖ ﻛﻠﻤﺔ ﻧﻌﻢ‬P ‫ﻳﺮﺟﻰ ﺍﻹﻓﺼﺎﺡ ﻋﻦ ﻭﺟﻮﺩ ﺃﻱ ﻣﻦ ﺍﻟﺤﺎﻻﺕ ﺍﺩﻧﺎﻩ ﺑﻮﺿﻊ ﺇﺷﺎﺭﺓ‬
"Below Undeclared Medical Case May Not Be Covered" No / ‫ﻻ‬ Yes / ‫ﻧﻌـﻢ‬ "‫"ﻟﻦ ﺗﺘﻢ ﺍﻟﺘﻐﻄﻴﺔ ﺍﻟﺘﺄﻣﻴﻨﻴﺔ ﻟﻠﺤﺎﻻﺕ ﺃﺩﻧﺎﻩ ﻓﻰ ﺣﺎﻝ ﻋﺪﻡ ﺍﻹﻓﺼﺎﺡ ﻋﻨﻬﺎ‬
Any hospital admission during last 12 months. ‫ ﺷﻬﺮ‬12 ‫ﻫﻞ ﺗﻢ ﺍﻟﺘﻨﻮﻳﻢ ﺑﺎﻟﻤﺴﺘﺸﻔﻰ ﺧﻼﻝ ﺃﺧﺮ‬
"Admission: registering as an admitted patient at the hospital until the following morning "
* * " ‫ ﺗﺴﺠﻴﻞ ﺍﻟﺸﺨﺺ ﺍﻟﻤﺆﻣﻦ ﻟﻪ ﻛﻤﺮﻳﺾ ﻣﻨﻮﻡ ﻓﻲ ﺍﻟﻤﺴﺘﺸﻔﻰ ﺣﺘﻰ ﺻﺒﺎﺡ ﺍﻟﻴﻮﻡ ﺍﻟﺘﺎﻟﻲ‬: ‫" ﺍﻟﺘﻨﻮﻳﻢ‬

Have you been diagnosed with any of the following chronic disease limited ‫ﻫﻞ ﺗﻢ ﺗﺸﺨﻴﺼﻚ ﺑﺄﻯ ﻣﻦ ﺍﻷﻣﺮﺍﺽ ﺍﻟﺘﺎﻟﻴﺔ ﻓﻘﻂ‬
to:Autism, listed Benign Tumor (Breast tumors, fibroid uterus, benign prostatic hyperplasia, ‫ﺃﻭﺭﺍﻡ ﺃﻭ‬,‫ﺗﻀﺨﻢ ﺍﻟﺒﺮﻭﺳﺘﺎﺗﺎ ﺍﻟﺤﻤﻴﺪ‬,‫ ﺃﻭﺭﺍﻡ ﺍﻟﺮﺣﻢ ﺍﻟﻠﻴﻔﻰ‬, ‫ﺍﻻﻭﺭﺍﻡ ﺍﻟﺤﻤﻴﺪﺓ ﺍﻟﺘﺎﻟﻴﺔ )ﺃﻭﺭﺍﻡ ﺍﻟﺜﺪﻯ‬,‫ﺍﻷﻭﺭﺍﻡ ﺍﻟﺴﺮﻃﺎﻧﻴﺔ‬,‫ﺍﻟﺘﻮﺣﺪ‬
thyroid goiter and parathyroid glands, live tumors, colon tumors). Malignant tumors, listed ‫ﺃﻣﺮﺍﺽ ﺍﻟﻘﻠﺐ ﺍﻟﺘﺎﻟﻴﺔ)ﺃﻣﺮﺍﺽ ﺷﺮﺍﻳﻴﻦ ﻭﺻﻤﺎﻣﺎﺕ ﺗﻀﺨﻢ ﺍﻟﻐﺪﺓ ﺍﻟﺪﺭﻗﻴﺔ‬, (‫ﺃﻭﺭﺍﻡ ﺍﻟﻘﻮﻟﻮﻥ‬, ‫ﻭﺃﻭﺭﺍﻡ ﺍﻻﻟﻜﺒﺪ‬,‫ﻭ ﺍﻟﺠﺎﺭ ﺍﻟﺪﺭﻗﻴﺔ‬
Cardiac diseases coronary and valve heart diseases, heart failure, cardiac fibrillation
myocardial infraction, heart clots). Chronic Hepatitis C. Gallstones Sever Kidney failure (stage
* * ‫ﺍﻻﻟﺘﻬﺎﺏ ﺍﻟﻜﺒﺪﻯ ﺍﻟﻔﻴﺮﻭﺳﻰ ﺍﻟﻤﺰﻣﻦ‬.( ‫ﺍﻟﺮﺟﻔﺎﻥ ﺍﻟﻘﻠﺒﻰ ﻭﺟﻠﻄﺎﺕ ﺍﻟﻘﻠﺐ‬, ‫ﻓﺸﻞ ﻋﻀﻠﺔ ﺍﻟﻘﻠﺐ‬, ‫ﺣﺼﻮﺍﺕ ﺍﻟﻤﺮﺍﺭﺓ ﺍﻟﻘﻠﺐ‬, ‫ﺝ ﻭﺳﻰ‬
,‫ ﺍﻟﺘﺮﺷﻴﺢ ﺍﻟﻜﻠﻮﻯ ﺃﻗﻞ ﻣﻦ‬,‫ ﺍﻟﻔﺸﻞ ﺍﻟﻜﻠﻮﻯﺍﻟﺸﺪﻳﺪ )ﺍﻟﻤﺮﺣﻠﺔ ﺍﻟﺨﺎﻣﺴﺔ ﻣﻦ ﺍﻣﺮﺍﺽ ﺍﻟﻜﻠﻰ ﺍﻟﺘﻰ ﺗﺴﺘﺪﻋﻰ ﺍﻟﻐﺴﻴﻞ ﺍﻟﻜﻠﻮﻯ‬15
5 Requiring dialysis, clearance of less tha 15 ml/ minute*). Urinary tract ‫ﻣﺮﺽ‬, ‫ﺩﻗﻴﻘﺔ(ﺣﺼﻮﺍﺕ ﺍﻟﻤﺴﺎﻟﻚ ﺍﻟﺒﻮﻟﻴﺔﺃﻣﺮﺍﺽ ﺍﻟﻤﻨﺎﻋﺔ ﺍﻟﺘﺎﻟﻴﺔ )ﺍﻟﺬﺋﺒﺔ ﺍﻟﺤﻤﺮﺍﺀﻭﺍﻟﺘﻬﺎﺏ ﺍﻟﻤﻔﺎﺻﻞ ﺍﻟﺮﻭﻣﺎﺗﻴﺰﻣﻴﺔﻭ ﺍﻟﺼﺪﻓﻴﺔ‬/‫ﻣﻞ‬
stones, hernias. Autoimmune disease (lupus, rheumatoid arthritis, psoriasis, Crohn's disease, ‫ﺍﻟﺘﻬﺎﺏ ﺍﻟﻘﻮﻟﻮﻥ ﺍﻟﺘﻘﺮﺣﻰ‬, ‫ﻛﺮﻭﻧﺰ‬,
ulcerative colitis,multiple sclerosis, celiac disease) ‫ﺣﺴﺎﺳﻴﺔ ﺍﻟﻘﻤﺢ‬, ‫ﺍﻟﺘﺼﻠﺐ ﺍﻟﻠﻮﻳﺤﻰ‬

Have you been diagnosed with any of the following congenital disorder or
hereditary diseases limited to: Cerebral palsy, Sickle cell disorder, Thalassemia, ‫ﻫﻞ ﺗﻢ ﺗﺸﺨﻴﺼﻚ ﺑﺄﻱ ﻣﻦ ﺍﻷﻣﺮﺍﺽ ﺍﻟﻮﺭﺍﺛﻴﺔ ﺃﻭ ﺍﻟﺘﺸﻮﻫﺎﺕ ﺍﻟﺨﻠﻘﻴﺔ ﺍﻟﺘﺎﻟﻴﺔ ﻓﻘﻂ‬
hemophilia, metabolic diseases, Hydrocephalus, spinal muscle atrophy, genital ‫ ﺿﻤﻮﺭ‬،‫ ﺃﺳﺘﺴﻘﺎﺀ ﺍﻟﺮﺃﺱ‬،‫ ﺃﻣﺮﺍﺽ ﺍﻟﺘﻤﺜﻴﻞ ﺍﻟﻐﺬﺍﺋﻲ‬،‫ ﺍﻟﻬﻴﻤﻮﻓﻴﻠﻴﺎ‬،‫ ﺍﻟﺘﻼﺳﻴﻤﻴﺎ‬،‫ﺍﺿﻄﺮﺍﺏ ﺍﻟﺨﻼﻳﺎ ﺍﻟﻤﻨﺠﻠﻴﺔ‬, ‫ﺍﻟﺸﻠﻞ ﺍﻟﺪﻣﺎﻏﻰ‬
malformations, chromosomal abnormalities. Gaucher's disease, G6PD Deficiency, cystic
fibrosis, hemochromatosis, Wilson disease. Polycystic Kidney Disease.
* * ‫ ﻣﺮﺽ ﺍﻟﺘﻜﺴﺮﺍﻟﻔﻮﻟﻰ‬،‫ ﻣﺮﺽ ﻏﻮﺷﺮ‬،‫ ﺃﻣﺮﺍﺽ ﺍﻟﻜﺮﻭﻣﻮﺳﻮﻣﺎﺕ‬،‫ ﺗﺸﻮﻫﺎﺕ ﺍﻷﻋﻀﺎﺀ ﺍﻟﺘﻨﺎﺳﻠﻴﺔ‬،‫ﺍﻟﻌﻀﻼﺕ ﺍﻟﺸﻮﻛﻲ‬
‫ﺗﻜﻴﺲ‬,‫ﻣﺮﺽ ﻭﻳﻠﺴﻮﻥ‬, (‫ ﻣﺮﺽ ﺗﻜﺪﺱ ﺍﻟﺤﺪﻳﺪ )ﻫﻴﻤﻮﻛﺮﻭﻣﺎﺗﻮﺳﻴﺲ‬،‫( ﺍﻟﺘﻠﻴﻒ ﺍﻟﻜﻴﺴﻲ ﻟﻠﺮﺋﺔ‬G6PD)
‫ﺍﻟﻜﻠﻴﺘﻴﻦ ﺍﻟﺨﻠﻔﻰ ﺍﻟﻮﺭﺍﺋﻰ‬

Have you been diagnosed with any of following eye diseases limited to: ،‫ ﻣﻴﺎﺓ ﺯﺭﻗﺎﺀ‬،‫ ﻣﻴﺎﺓ ﺑﻴﻀﺎﺀ‬:‫ﻫﻞ ﺗﻢ ﺗﺸﺨﻴﺼﻚ ﺑﺄﻱ ﻣﻦ ﺃﻣﺮﺍﺽ ﺍﻟﻌﻴﻦ ﺍﻟﺘﺎﻟﻴﺔ ﻓﻘﻂ‬
Cataract, Glaucoma, Retinal diseases. * * ‫ﺃﻣﺮﺍﺽ ﺍﻟﺸﺒﻜﻴﺔ‬
Have you been diagnosed with any of the following bone diseases limited ‫ ﺍﻹﻧﺰﻻﻕ ﺍﻟﻐﻀﺮﻭﻓﻲ‬:‫ﻫﻞ ﺗﻢ ﺗﺸﺨﻴﺼﻚ ﺑﺄﻱ ﻣﻦ ﺃﻣﺮﺍﺽ ﺍﻟﻌﻈﺎﻡ ﺍﻟﺘﺎﻟﻴﺔ ﻓﻘﻂ‬
to:Vertebral disc prolapse (moderate or severe), Scoliosis (moderate or severe)**, or ligament
tears, osteoarthritis (moderate or severe )
* * ‫ﺗﻤﺰﻕ ﺍﻷﺭﺑﻄﺔ‬،‫ﺍﻟﺘﻬﺎﺏ ﺍﻟﻤﻔﺎﺻﻞ‬،‫ﺇﻧﺤﺮﺍﻑ ﺍﻟﻌﻤﻮﺩ ﺍﻟﻔﻘﺮﻱ‬,‫ﺍﻟﺪﻳﺴﻚ‬

Pregnant Female Only ‫ﻟﻸﻧﺜﻰ ﺍﻟﺤﺎﻣﻞ ﻓﻘﻂ‬

‫ﺣﻤﻞ ﺣﺎﻟﻲ ﺟﻨﻴﻦ ﻭﺍﺣﺪ‬
Current Single Pregnancy
* *
‫ﺣﻤﻞ ﺣﺎﻟﻲ ﻣﻊ ﻗﻴﺼﺮﻳﺔ ﺳﺎﺑﻘﺔ‬
Current Single Pregnancy with Previous CS Delivery
* *
‫ﺣﻤﻞ ﺣﺎﻟﻲ ﻣﺘﻌﺪﺩ ﺍﻷﺟﻨﺔ‬
Current Multiple Pregnancy
* *
Expected delivery date .. / .. / .... ‫ﺗﺎﺭﻳﺦ ﺍﻟﻮﻻﺩﺓ ﺍﻟﻤﺘﻮﻗﻊ‬
Employee and dependents details that need to be added ‫ﺑﻴﺎﻧﺎﺕ ﺍﻟﻤﻮﻇﻒ ﻭﺃﻓﺮﺍﺩ ﺍﻟﻌﺎﺋﻠﺔ ﺍﻟﻤﺮﺍﺩ ﺇﺿﺎﻓﺘﻬﻢ‬
In case of a yes answer above, please declare the case in the table below ‫ ﺍﻟﺮﺟﺎﺀ ﺫﻛﺮ ﺍﻟﺤﺎﻟﺔ ﻓﻲ ﺍﻟﺠﺪﻭﻝ ﺃﺩﻧﺎﻩ‬،‫ﻓﻲ ﺣﺎﻟﺔ ﺍﻹﺟﺎﺑﺔ ﺑﻨﻌﻢ ﺃﻋﻼﻩ‬
‫ﺇﺳﻢ ﻣﻘﺪﻡ ﺍﻟﺨﺪﻣﺔ‬ ‫ﺍﻟﺤﺎﻟﺔ‬ ‫ﺭﻗﻢ ﺍﻟﺠﻮﺍﻝ‬ ‫ﺍﻟﻄﻮﻝ‬ ‫ﺍﻟﻮﺯﻥ‬ ‫ﺭﻗﻢ ﺍﻟﻬﻮﻳﺔ‬ ‫ﺍﻟﻘﺮﺍﺑﺔ‬ ‫ﺍﻟﺠﻨﺲ‬ ‫ ﺃﻓﺮﺍﺩ ﺍﻟﻌﺎﺋﻠﺔ‬/ ‫ﺍﺳﻢ ﺍﻟﻤﻮﻇﻒ‬ ‫ﻡ‬
2285639288 Child Female / ‫ ﺃﻧﺜﻰ‬Abeer Mohammed Al Siddiqu 1
2
3
4
5
Undertakings : ‫ﺍﻹﻗﺮﺍﺭ ﻭﺍﻟﺘﻔﻮﻳﺾ‬
1- I hereby undertake that all the above information is correct and the acceptance of my ‫ﻭﺍﻟﻤﻌﻠﻮﻣﺎﺕ ﺍﻟﻤﺬﻛﻮﺭﺓ ﺃﻋﻼﻩ ﻛﺎﻣﻠﺔ ﻭﺻﺤﻴﺤﺔ ﻭﺑﻨﺎﺀ ﻋﻠﻴﻪ ﻓﺈﻥ ﻗﺒﻮﻝ ﺍﻟﻄﻠﺐ ﺳﻴﺘﻢ‬: ‫ ﺃﻗﺮ ﺃﻥ ﺍﻟﺒﻴﺎﻧﺎﺕ‬-1
enrollment will be on the basis of such information and that Malath Cooperative Insurance ‫ﻋﻠﻰ ﺃﺳﺎﺱ ﻫﺬﻩ ﺍﻟﺒﻴﺎﻧﺎﺕ ﻭﺃﻥ ﺷﺮﻛﺔ ﻣﻼﺫ ﻟﻠﺘﺄﻣﻴﻦ ﺍﻟﺘﻌﺎﻭﻧﻲ ﻟﻬﺎ ﺍﻟﺤﻖ ﻓﻲ ﺍﻻﺗﺼﺎﻝ ﺑﺎﻟﻤﺴﺘﺸﻔﻴﺎﺕ ﺍﻟﺘﻲ‬
Company has the right to contact the hospital(s) I deal with to collect any ‫ﺃﺗﻌﺎﻣﻞ ﻣﻌﻬﺎ ﻟﺘﺰﻭﻳﺪﻫﺎ ﺑﺄﻱ ﻣﻌﻠﻮﻣﺎﺕ ﻃﺒﻴﺔ ﻗﺪ ﺗﺤﺘﺎﺝ ﺇﻟﻴﻬﺎ ﻟﺘﻘﻴﻴﻢ ﺍﻟﻤﺨﺎﻃﺮ‬
medical information needed to assess the risk(s).

2- I agree that Malath Cooperative Insurance Company has the right to reject the ‫ ﺃﻭﺍﻓﻖ ﻋﻠﻰ ﺃﺣﻘﻴﺔ ﺷﺮﻛﺔ ﻣﻼﺫ ﻟﻠﺘﺄﻣﻴﻦ ﻓﻲ ﺭﻓﺾ ﺍﻟﻤﻄﺎﻟﺒﺔ ﺃﻭ ﺍﻟﺘﻐﻄﻴﺔ ﻛﻠﻴﺎ ﻋﻨﺪ ﻋﺪﻡ ﺍﻹﻓﺼﺎﺡ ﻋﻦ ﻭﺟﻮﺩ ﺃﻱ ﻣﻦ ﺍﻟﺤﺎﻻﺕ‬-2
coverage/claims in full in case of no declaration of any cases prior to the contractual date or ‫ﺍﻟﻤﺬﻛﻮﺭﺓ ﺃﻋﻼﻩ ﺍﻟﺘﻲ ﻧﺸﺄﺕ ﻗﺒﻞ ﺗﺎﺭﻳﺦ ﺍﻟﺘﻌﺎﻗﺪ ﺃﻭ ﻗﺒﻞ ﺗﺴﺠﻴﻞ ﺃﻭ ﺇﺿﺎﻓﺔ ﻋﻀﻮ ﺧﻼﻝ ﻓﺘﺮﺓ ﺳﺮﻳﺎﻥ ﺍﻟﻌﻘﺪ‬
before enrolling or adding a new member during the contract.

3- I hereby confirm reading and understanding all points presented in this form and I agree that ‫ ﺃﻗﺮﺑﺄﻧﻲ ﻗﺪ ﻗﺮﺃﺕ ﻭﻓﻬﻤﺖ ﺟﻤﻴﻊ ﻣﺎ ﺟﺎﺀ ﻓﻲ ﻫﺬﺍ ﺍﻟﻨﻤﻮﺫﺝ ﻛﻤﺎ ﺃﺗﻌﻬﺪ ﺑﺄﻥ ﻋﺪﻡ ﺇﺷﺎﺭﺗﻲ ﺃﻣﺎﻡ ﺃﻱ ﻣﻦ‬-3
not marking any case is understood as “Nothing requires declaration” and I sign on these ‫ﺍﻟﺤﺎﻻﺕ ﺍﻟﻤﺬﻛﻮﺭﺓ ﺃﻋﻼﻩ ﻳﻌﺘﺒﺮ ﺑﻤﺜﺎﺑﺔ ﻧﻔﻲ ﻭﺟﻮﺩ ﻣﺎﻳﺴﺘﺤﻖ ﺍﻹﻓﺼﺎﺡ ﻋﻨﻪ ﻭﻋﻠﻴﻪ ﺃﻭﻗﻊ‬
basis.
4- Failure to fill the weight and height information will result in refusal to cover
the cost of obesity surgery. ‫ ﻋﺪﻡ ﺗﻌﺒﺌﺔ ﺑﻴﺎﻧﺎﺕ ﺍﻟﻄﻮﻝ ﻭﺍﻟﻮﺯﻥ ﺳﻴﺆﺩﻱ ﺇﻟﻰ ﺭﻓﺾ ﺗﻐﻄﻴﺔ ﺗﻜﺎﻟﻴﻒ ﻋﻤﻠﻴﺔ ﺟﺮﺍﺣﺔ ﺍﻟﺴﻤﻨﺔ ﺍﻟﻤﻔﺮﻃﺔ‬-4

Entity's stamp ‫ﺧﺘﻢ ﺟﻬﺔ ﺍﻟﻌﻤﻞ‬ Insured Signature ‫ﺗﻮﻗﻴﻊ ﺍﻟﻤﻮﻇﻒ‬ Date ‫ﺍﻟﺘﺎﺭﻳﺦ‬
.. / .. / ....

New_Health_Insurance.rdf Page 13 of 39 V.20 13-DEC-2023 01:30 PM

 ‫ﻧﻤﻮﺫﺝ ﺍﻻﻓﺼﺎﺡ ﺍﻟﻄﺒﻲ ﺍﻟﻤﻮﺣﺪ‬
Unified Medical Declaration Form
Product Code: A-MLTH-2-C-08-014
Dear Insured: ‫ﻋﺰﻳﺰﻱ ﺍﻟﻤﺆﻣﻦ ﻟﻪ‬
Please Fill out the form correctly for the purpose of pricing and to ensured that you and your ‫ﻧﺄﻣﻞ ﻗﻴﺎﻣﻚ ﺑﺘﻌﺒﺌﺔ ﻫﺬﺍ ﺍﻟﻨﻤﻮﺫﺝ ﺑﺎﻟﺸﻜﻞ ﺍﻟﺼﺤﻴﺢ ﻟﻐﺮﺽ ﺍﻟﺘﺴﻌﻴﺮ ﻭﻟﻀﻤﺎﻥ ﺣﺼﻮﻟﻚ ﻭﺃﻓﺮﺍﺩ ﺃﺳﺮﺗﻚ ﻋﻠﻰ ﺧﺪﻣﺎﺕ‬
family receive health care services as required according to your unfied policy benefit ‫ﺍﻟﺮﻋﺎﻳﺔ ﺍﻟﺼﺤﻴﺔ ﺑﺎﻟﺸﻜﻞ ﺍﻟﻤﻄﻠﻮﺏ ﺣﺴﺐ ﻣﻨﺎﻓﻊ ﺍﻟﻮﺛﻴﻘﺔ ﺍﻟﻤﻮﺣﺪﺓ‬

Addition ‫ﺇﺿﺎﻓﺔ‬ New ‫ﺟﺪﻳﺪ‬ Type ‫ﻧﻮﻉ ﺍﻟﻄﻠﺐ‬

CR No 7011507360 ‫ﺍﻟﺴﺠﻞ ﺍﻟﺘﺠﺎﺭﻱ‬ Entity Name HADDAJ AL HIJAZ EST ‫ﺃﺳﻢ ﺍﻟﻤﻨﺸﺄﺓ‬
Mobile No 0509300773 ‫ﺭﻗﻢ ﺍﻟﺠﻮﺍﻝ‬ Rzan Mohammed Khaliq Ullah ‫ﺍﺳﻢ ﺍﻟﻤﻮﻇﻒ‬
ID Number 2 4 1 5 1 8 4 6 4 3 ‫ﺭﻗﻢ ﺍﻟﻬﻮﻳﺔ‬
Gender Female / ‫ﺍﻟﺠﻨﺲ ﺃﻧﺜﻰ‬ Nationality India ‫ ﺍﻟﺠﻨﺴﻴﺔ‬Marital status Married * ‫ﻣﺘﺰﻭﺝ‬ Single R ‫ﺃﻋﺰﺏ‬ ‫ﺍﻟﺤﺎﻟﺔ ﺍﻻﺟﺘﻤﺎﻋﻴﺔ‬
Please declare any of the below cases by marking P under the word Yes ‫ ﻓﻲ ﺍﻟﻤﺮﺑﻊ ﺗﺤﺖ ﻛﻠﻤﺔ ﻧﻌﻢ‬P ‫ﻳﺮﺟﻰ ﺍﻹﻓﺼﺎﺡ ﻋﻦ ﻭﺟﻮﺩ ﺃﻱ ﻣﻦ ﺍﻟﺤﺎﻻﺕ ﺍﺩﻧﺎﻩ ﺑﻮﺿﻊ ﺇﺷﺎﺭﺓ‬
"Below Undeclared Medical Case May Not Be Covered" No / ‫ﻻ‬ Yes / ‫ﻧﻌـﻢ‬ "‫"ﻟﻦ ﺗﺘﻢ ﺍﻟﺘﻐﻄﻴﺔ ﺍﻟﺘﺄﻣﻴﻨﻴﺔ ﻟﻠﺤﺎﻻﺕ ﺃﺩﻧﺎﻩ ﻓﻰ ﺣﺎﻝ ﻋﺪﻡ ﺍﻹﻓﺼﺎﺡ ﻋﻨﻬﺎ‬
Any hospital admission during last 12 months. ‫ ﺷﻬﺮ‬12 ‫ﻫﻞ ﺗﻢ ﺍﻟﺘﻨﻮﻳﻢ ﺑﺎﻟﻤﺴﺘﺸﻔﻰ ﺧﻼﻝ ﺃﺧﺮ‬
"Admission: registering as an admitted patient at the hospital until the following morning "
* * " ‫ ﺗﺴﺠﻴﻞ ﺍﻟﺸﺨﺺ ﺍﻟﻤﺆﻣﻦ ﻟﻪ ﻛﻤﺮﻳﺾ ﻣﻨﻮﻡ ﻓﻲ ﺍﻟﻤﺴﺘﺸﻔﻰ ﺣﺘﻰ ﺻﺒﺎﺡ ﺍﻟﻴﻮﻡ ﺍﻟﺘﺎﻟﻲ‬: ‫" ﺍﻟﺘﻨﻮﻳﻢ‬

Have you been diagnosed with any of the following chronic disease limited ‫ﻫﻞ ﺗﻢ ﺗﺸﺨﻴﺼﻚ ﺑﺄﻯ ﻣﻦ ﺍﻷﻣﺮﺍﺽ ﺍﻟﺘﺎﻟﻴﺔ ﻓﻘﻂ‬
to:Autism, listed Benign Tumor (Breast tumors, fibroid uterus, benign prostatic hyperplasia, ‫ﺃﻭﺭﺍﻡ ﺃﻭ‬,‫ﺗﻀﺨﻢ ﺍﻟﺒﺮﻭﺳﺘﺎﺗﺎ ﺍﻟﺤﻤﻴﺪ‬,‫ ﺃﻭﺭﺍﻡ ﺍﻟﺮﺣﻢ ﺍﻟﻠﻴﻔﻰ‬, ‫ﺍﻻﻭﺭﺍﻡ ﺍﻟﺤﻤﻴﺪﺓ ﺍﻟﺘﺎﻟﻴﺔ )ﺃﻭﺭﺍﻡ ﺍﻟﺜﺪﻯ‬,‫ﺍﻷﻭﺭﺍﻡ ﺍﻟﺴﺮﻃﺎﻧﻴﺔ‬,‫ﺍﻟﺘﻮﺣﺪ‬
thyroid goiter and parathyroid glands, live tumors, colon tumors). Malignant tumors, listed ‫ﺃﻣﺮﺍﺽ ﺍﻟﻘﻠﺐ ﺍﻟﺘﺎﻟﻴﺔ)ﺃﻣﺮﺍﺽ ﺷﺮﺍﻳﻴﻦ ﻭﺻﻤﺎﻣﺎﺕ ﺗﻀﺨﻢ ﺍﻟﻐﺪﺓ ﺍﻟﺪﺭﻗﻴﺔ‬, (‫ﺃﻭﺭﺍﻡ ﺍﻟﻘﻮﻟﻮﻥ‬, ‫ﻭﺃﻭﺭﺍﻡ ﺍﻻﻟﻜﺒﺪ‬,‫ﻭ ﺍﻟﺠﺎﺭ ﺍﻟﺪﺭﻗﻴﺔ‬
Cardiac diseases coronary and valve heart diseases, heart failure, cardiac fibrillation
myocardial infraction, heart clots). Chronic Hepatitis C. Gallstones Sever Kidney failure (stage
* * ‫ﺍﻻﻟﺘﻬﺎﺏ ﺍﻟﻜﺒﺪﻯ ﺍﻟﻔﻴﺮﻭﺳﻰ ﺍﻟﻤﺰﻣﻦ‬.( ‫ﺍﻟﺮﺟﻔﺎﻥ ﺍﻟﻘﻠﺒﻰ ﻭﺟﻠﻄﺎﺕ ﺍﻟﻘﻠﺐ‬, ‫ﻓﺸﻞ ﻋﻀﻠﺔ ﺍﻟﻘﻠﺐ‬, ‫ﺣﺼﻮﺍﺕ ﺍﻟﻤﺮﺍﺭﺓ ﺍﻟﻘﻠﺐ‬, ‫ﺝ ﻭﺳﻰ‬
,‫ ﺍﻟﺘﺮﺷﻴﺢ ﺍﻟﻜﻠﻮﻯ ﺃﻗﻞ ﻣﻦ‬,‫ ﺍﻟﻔﺸﻞ ﺍﻟﻜﻠﻮﻯﺍﻟﺸﺪﻳﺪ )ﺍﻟﻤﺮﺣﻠﺔ ﺍﻟﺨﺎﻣﺴﺔ ﻣﻦ ﺍﻣﺮﺍﺽ ﺍﻟﻜﻠﻰ ﺍﻟﺘﻰ ﺗﺴﺘﺪﻋﻰ ﺍﻟﻐﺴﻴﻞ ﺍﻟﻜﻠﻮﻯ‬15
5 Requiring dialysis, clearance of less tha 15 ml/ minute*). Urinary tract ‫ﻣﺮﺽ‬, ‫ﺩﻗﻴﻘﺔ(ﺣﺼﻮﺍﺕ ﺍﻟﻤﺴﺎﻟﻚ ﺍﻟﺒﻮﻟﻴﺔﺃﻣﺮﺍﺽ ﺍﻟﻤﻨﺎﻋﺔ ﺍﻟﺘﺎﻟﻴﺔ )ﺍﻟﺬﺋﺒﺔ ﺍﻟﺤﻤﺮﺍﺀﻭﺍﻟﺘﻬﺎﺏ ﺍﻟﻤﻔﺎﺻﻞ ﺍﻟﺮﻭﻣﺎﺗﻴﺰﻣﻴﺔﻭ ﺍﻟﺼﺪﻓﻴﺔ‬/‫ﻣﻞ‬
stones, hernias. Autoimmune disease (lupus, rheumatoid arthritis, psoriasis, Crohn's disease, ‫ﺍﻟﺘﻬﺎﺏ ﺍﻟﻘﻮﻟﻮﻥ ﺍﻟﺘﻘﺮﺣﻰ‬, ‫ﻛﺮﻭﻧﺰ‬,
ulcerative colitis,multiple sclerosis, celiac disease) ‫ﺣﺴﺎﺳﻴﺔ ﺍﻟﻘﻤﺢ‬, ‫ﺍﻟﺘﺼﻠﺐ ﺍﻟﻠﻮﻳﺤﻰ‬

Have you been diagnosed with any of the following congenital disorder or
hereditary diseases limited to: Cerebral palsy, Sickle cell disorder, Thalassemia, ‫ﻫﻞ ﺗﻢ ﺗﺸﺨﻴﺼﻚ ﺑﺄﻱ ﻣﻦ ﺍﻷﻣﺮﺍﺽ ﺍﻟﻮﺭﺍﺛﻴﺔ ﺃﻭ ﺍﻟﺘﺸﻮﻫﺎﺕ ﺍﻟﺨﻠﻘﻴﺔ ﺍﻟﺘﺎﻟﻴﺔ ﻓﻘﻂ‬
hemophilia, metabolic diseases, Hydrocephalus, spinal muscle atrophy, genital ‫ ﺿﻤﻮﺭ‬،‫ ﺃﺳﺘﺴﻘﺎﺀ ﺍﻟﺮﺃﺱ‬،‫ ﺃﻣﺮﺍﺽ ﺍﻟﺘﻤﺜﻴﻞ ﺍﻟﻐﺬﺍﺋﻲ‬،‫ ﺍﻟﻬﻴﻤﻮﻓﻴﻠﻴﺎ‬،‫ ﺍﻟﺘﻼﺳﻴﻤﻴﺎ‬،‫ﺍﺿﻄﺮﺍﺏ ﺍﻟﺨﻼﻳﺎ ﺍﻟﻤﻨﺠﻠﻴﺔ‬, ‫ﺍﻟﺸﻠﻞ ﺍﻟﺪﻣﺎﻏﻰ‬
malformations, chromosomal abnormalities. Gaucher's disease, G6PD Deficiency, cystic
fibrosis, hemochromatosis, Wilson disease. Polycystic Kidney Disease.
* * ‫ ﻣﺮﺽ ﺍﻟﺘﻜﺴﺮﺍﻟﻔﻮﻟﻰ‬،‫ ﻣﺮﺽ ﻏﻮﺷﺮ‬،‫ ﺃﻣﺮﺍﺽ ﺍﻟﻜﺮﻭﻣﻮﺳﻮﻣﺎﺕ‬،‫ ﺗﺸﻮﻫﺎﺕ ﺍﻷﻋﻀﺎﺀ ﺍﻟﺘﻨﺎﺳﻠﻴﺔ‬،‫ﺍﻟﻌﻀﻼﺕ ﺍﻟﺸﻮﻛﻲ‬
‫ﺗﻜﻴﺲ‬,‫ﻣﺮﺽ ﻭﻳﻠﺴﻮﻥ‬, (‫ ﻣﺮﺽ ﺗﻜﺪﺱ ﺍﻟﺤﺪﻳﺪ )ﻫﻴﻤﻮﻛﺮﻭﻣﺎﺗﻮﺳﻴﺲ‬،‫( ﺍﻟﺘﻠﻴﻒ ﺍﻟﻜﻴﺴﻲ ﻟﻠﺮﺋﺔ‬G6PD)
‫ﺍﻟﻜﻠﻴﺘﻴﻦ ﺍﻟﺨﻠﻔﻰ ﺍﻟﻮﺭﺍﺋﻰ‬

Have you been diagnosed with any of following eye diseases limited to: ،‫ ﻣﻴﺎﺓ ﺯﺭﻗﺎﺀ‬،‫ ﻣﻴﺎﺓ ﺑﻴﻀﺎﺀ‬:‫ﻫﻞ ﺗﻢ ﺗﺸﺨﻴﺼﻚ ﺑﺄﻱ ﻣﻦ ﺃﻣﺮﺍﺽ ﺍﻟﻌﻴﻦ ﺍﻟﺘﺎﻟﻴﺔ ﻓﻘﻂ‬
Cataract, Glaucoma, Retinal diseases. * * ‫ﺃﻣﺮﺍﺽ ﺍﻟﺸﺒﻜﻴﺔ‬
Have you been diagnosed with any of the following bone diseases limited ‫ ﺍﻹﻧﺰﻻﻕ ﺍﻟﻐﻀﺮﻭﻓﻲ‬:‫ﻫﻞ ﺗﻢ ﺗﺸﺨﻴﺼﻚ ﺑﺄﻱ ﻣﻦ ﺃﻣﺮﺍﺽ ﺍﻟﻌﻈﺎﻡ ﺍﻟﺘﺎﻟﻴﺔ ﻓﻘﻂ‬
to:Vertebral disc prolapse (moderate or severe), Scoliosis (moderate or severe)**, or ligament
tears, osteoarthritis (moderate or severe )
* * ‫ﺗﻤﺰﻕ ﺍﻷﺭﺑﻄﺔ‬،‫ﺍﻟﺘﻬﺎﺏ ﺍﻟﻤﻔﺎﺻﻞ‬،‫ﺇﻧﺤﺮﺍﻑ ﺍﻟﻌﻤﻮﺩ ﺍﻟﻔﻘﺮﻱ‬,‫ﺍﻟﺪﻳﺴﻚ‬

Pregnant Female Only ‫ﻟﻸﻧﺜﻰ ﺍﻟﺤﺎﻣﻞ ﻓﻘﻂ‬

‫ﺣﻤﻞ ﺣﺎﻟﻲ ﺟﻨﻴﻦ ﻭﺍﺣﺪ‬
Current Single Pregnancy
* *
‫ﺣﻤﻞ ﺣﺎﻟﻲ ﻣﻊ ﻗﻴﺼﺮﻳﺔ ﺳﺎﺑﻘﺔ‬
Current Single Pregnancy with Previous CS Delivery
* *
‫ﺣﻤﻞ ﺣﺎﻟﻲ ﻣﺘﻌﺪﺩ ﺍﻷﺟﻨﺔ‬
Current Multiple Pregnancy
* *
Expected delivery date .. / .. / .... ‫ﺗﺎﺭﻳﺦ ﺍﻟﻮﻻﺩﺓ ﺍﻟﻤﺘﻮﻗﻊ‬
Employee and dependents details that need to be added ‫ﺑﻴﺎﻧﺎﺕ ﺍﻟﻤﻮﻇﻒ ﻭﺃﻓﺮﺍﺩ ﺍﻟﻌﺎﺋﻠﺔ ﺍﻟﻤﺮﺍﺩ ﺇﺿﺎﻓﺘﻬﻢ‬
In case of a yes answer above, please declare the case in the table below ‫ ﺍﻟﺮﺟﺎﺀ ﺫﻛﺮ ﺍﻟﺤﺎﻟﺔ ﻓﻲ ﺍﻟﺠﺪﻭﻝ ﺃﺩﻧﺎﻩ‬،‫ﻓﻲ ﺣﺎﻟﺔ ﺍﻹﺟﺎﺑﺔ ﺑﻨﻌﻢ ﺃﻋﻼﻩ‬
‫ﺇﺳﻢ ﻣﻘﺪﻡ ﺍﻟﺨﺪﻣﺔ‬ ‫ﺍﻟﺤﺎﻟﺔ‬ ‫ﺭﻗﻢ ﺍﻟﺠﻮﺍﻝ‬ ‫ﺍﻟﻄﻮﻝ‬ ‫ﺍﻟﻮﺯﻥ‬ ‫ﺭﻗﻢ ﺍﻟﻬﻮﻳﺔ‬ ‫ﺍﻟﻘﺮﺍﺑﺔ‬ ‫ﺍﻟﺠﻨﺲ‬ ‫ ﺃﻓﺮﺍﺩ ﺍﻟﻌﺎﺋﻠﺔ‬/ ‫ﺍﺳﻢ ﺍﻟﻤﻮﻇﻒ‬ ‫ﻡ‬
2415184643 Child Female / ‫ ﺃﻧﺜﻰ‬Rzan Mohammed Khaliq Ulla 1
2
3
4
5
Undertakings : ‫ﺍﻹﻗﺮﺍﺭ ﻭﺍﻟﺘﻔﻮﻳﺾ‬
1- I hereby undertake that all the above information is correct and the acceptance of my ‫ﻭﺍﻟﻤﻌﻠﻮﻣﺎﺕ ﺍﻟﻤﺬﻛﻮﺭﺓ ﺃﻋﻼﻩ ﻛﺎﻣﻠﺔ ﻭﺻﺤﻴﺤﺔ ﻭﺑﻨﺎﺀ ﻋﻠﻴﻪ ﻓﺈﻥ ﻗﺒﻮﻝ ﺍﻟﻄﻠﺐ ﺳﻴﺘﻢ‬: ‫ ﺃﻗﺮ ﺃﻥ ﺍﻟﺒﻴﺎﻧﺎﺕ‬-1
enrollment will be on the basis of such information and that Malath Cooperative Insurance ‫ﻋﻠﻰ ﺃﺳﺎﺱ ﻫﺬﻩ ﺍﻟﺒﻴﺎﻧﺎﺕ ﻭﺃﻥ ﺷﺮﻛﺔ ﻣﻼﺫ ﻟﻠﺘﺄﻣﻴﻦ ﺍﻟﺘﻌﺎﻭﻧﻲ ﻟﻬﺎ ﺍﻟﺤﻖ ﻓﻲ ﺍﻻﺗﺼﺎﻝ ﺑﺎﻟﻤﺴﺘﺸﻔﻴﺎﺕ ﺍﻟﺘﻲ‬
Company has the right to contact the hospital(s) I deal with to collect any ‫ﺃﺗﻌﺎﻣﻞ ﻣﻌﻬﺎ ﻟﺘﺰﻭﻳﺪﻫﺎ ﺑﺄﻱ ﻣﻌﻠﻮﻣﺎﺕ ﻃﺒﻴﺔ ﻗﺪ ﺗﺤﺘﺎﺝ ﺇﻟﻴﻬﺎ ﻟﺘﻘﻴﻴﻢ ﺍﻟﻤﺨﺎﻃﺮ‬
medical information needed to assess the risk(s).

2- I agree that Malath Cooperative Insurance Company has the right to reject the ‫ ﺃﻭﺍﻓﻖ ﻋﻠﻰ ﺃﺣﻘﻴﺔ ﺷﺮﻛﺔ ﻣﻼﺫ ﻟﻠﺘﺄﻣﻴﻦ ﻓﻲ ﺭﻓﺾ ﺍﻟﻤﻄﺎﻟﺒﺔ ﺃﻭ ﺍﻟﺘﻐﻄﻴﺔ ﻛﻠﻴﺎ ﻋﻨﺪ ﻋﺪﻡ ﺍﻹﻓﺼﺎﺡ ﻋﻦ ﻭﺟﻮﺩ ﺃﻱ ﻣﻦ ﺍﻟﺤﺎﻻﺕ‬-2
coverage/claims in full in case of no declaration of any cases prior to the contractual date or ‫ﺍﻟﻤﺬﻛﻮﺭﺓ ﺃﻋﻼﻩ ﺍﻟﺘﻲ ﻧﺸﺄﺕ ﻗﺒﻞ ﺗﺎﺭﻳﺦ ﺍﻟﺘﻌﺎﻗﺪ ﺃﻭ ﻗﺒﻞ ﺗﺴﺠﻴﻞ ﺃﻭ ﺇﺿﺎﻓﺔ ﻋﻀﻮ ﺧﻼﻝ ﻓﺘﺮﺓ ﺳﺮﻳﺎﻥ ﺍﻟﻌﻘﺪ‬
before enrolling or adding a new member during the contract.

3- I hereby confirm reading and understanding all points presented in this form and I agree that ‫ ﺃﻗﺮﺑﺄﻧﻲ ﻗﺪ ﻗﺮﺃﺕ ﻭﻓﻬﻤﺖ ﺟﻤﻴﻊ ﻣﺎ ﺟﺎﺀ ﻓﻲ ﻫﺬﺍ ﺍﻟﻨﻤﻮﺫﺝ ﻛﻤﺎ ﺃﺗﻌﻬﺪ ﺑﺄﻥ ﻋﺪﻡ ﺇﺷﺎﺭﺗﻲ ﺃﻣﺎﻡ ﺃﻱ ﻣﻦ‬-3
not marking any case is understood as “Nothing requires declaration” and I sign on these ‫ﺍﻟﺤﺎﻻﺕ ﺍﻟﻤﺬﻛﻮﺭﺓ ﺃﻋﻼﻩ ﻳﻌﺘﺒﺮ ﺑﻤﺜﺎﺑﺔ ﻧﻔﻲ ﻭﺟﻮﺩ ﻣﺎﻳﺴﺘﺤﻖ ﺍﻹﻓﺼﺎﺡ ﻋﻨﻪ ﻭﻋﻠﻴﻪ ﺃﻭﻗﻊ‬
basis.
4- Failure to fill the weight and height information will result in refusal to cover
the cost of obesity surgery. ‫ ﻋﺪﻡ ﺗﻌﺒﺌﺔ ﺑﻴﺎﻧﺎﺕ ﺍﻟﻄﻮﻝ ﻭﺍﻟﻮﺯﻥ ﺳﻴﺆﺩﻱ ﺇﻟﻰ ﺭﻓﺾ ﺗﻐﻄﻴﺔ ﺗﻜﺎﻟﻴﻒ ﻋﻤﻠﻴﺔ ﺟﺮﺍﺣﺔ ﺍﻟﺴﻤﻨﺔ ﺍﻟﻤﻔﺮﻃﺔ‬-4

Entity's stamp ‫ﺧﺘﻢ ﺟﻬﺔ ﺍﻟﻌﻤﻞ‬ Insured Signature ‫ﺗﻮﻗﻴﻊ ﺍﻟﻤﻮﻇﻒ‬ Date ‫ﺍﻟﺘﺎﺭﻳﺦ‬
.. / .. / ....

New_Health_Insurance.rdf Page 14 of 39 V.20 13-DEC-2023 01:30 PM

 ‫ﻧﻤﻮﺫﺝ ﺍﻻﻓﺼﺎﺡ ﺍﻟﻄﺒﻲ ﺍﻟﻤﻮﺣﺪ‬
Unified Medical Declaration Form
Product Code: A-MLTH-2-C-08-014
Dear Insured: ‫ﻋﺰﻳﺰﻱ ﺍﻟﻤﺆﻣﻦ ﻟﻪ‬
Please Fill out the form correctly for the purpose of pricing and to ensured that you and your ‫ﻧﺄﻣﻞ ﻗﻴﺎﻣﻚ ﺑﺘﻌﺒﺌﺔ ﻫﺬﺍ ﺍﻟﻨﻤﻮﺫﺝ ﺑﺎﻟﺸﻜﻞ ﺍﻟﺼﺤﻴﺢ ﻟﻐﺮﺽ ﺍﻟﺘﺴﻌﻴﺮ ﻭﻟﻀﻤﺎﻥ ﺣﺼﻮﻟﻚ ﻭﺃﻓﺮﺍﺩ ﺃﺳﺮﺗﻚ ﻋﻠﻰ ﺧﺪﻣﺎﺕ‬
family receive health care services as required according to your unfied policy benefit ‫ﺍﻟﺮﻋﺎﻳﺔ ﺍﻟﺼﺤﻴﺔ ﺑﺎﻟﺸﻜﻞ ﺍﻟﻤﻄﻠﻮﺏ ﺣﺴﺐ ﻣﻨﺎﻓﻊ ﺍﻟﻮﺛﻴﻘﺔ ﺍﻟﻤﻮﺣﺪﺓ‬

Addition ‫ﺇﺿﺎﻓﺔ‬ New ‫ﺟﺪﻳﺪ‬ Type ‫ﻧﻮﻉ ﺍﻟﻄﻠﺐ‬

CR No 7011507360 ‫ﺍﻟﺴﺠﻞ ﺍﻟﺘﺠﺎﺭﻱ‬ Entity Name HADDAJ AL HIJAZ EST ‫ﺃﺳﻢ ﺍﻟﻤﻨﺸﺄﺓ‬
Mobile No 0509300773 ‫ﺭﻗﻢ ﺍﻟﺠﻮﺍﻝ‬ Hamdan Mohammed Khaliq Ullah ‫ﺍﺳﻢ ﺍﻟﻤﻮﻇﻒ‬
ID Number 2 4 7 7 6 6 5 3 2 3 ‫ﺭﻗﻢ ﺍﻟﻬﻮﻳﺔ‬
Male / ‫ﺫﻛﺮ‬ India
Gender ‫ ﺍﻟﺠﻨﺲ‬Nationality ‫ ﺍﻟﺠﻨﺴﻴﺔ‬Marital status Married * ‫ﻣﺘﺰﻭﺝ‬ Single R ‫ﺃﻋﺰﺏ‬ ‫ﺍﻟﺤﺎﻟﺔ ﺍﻻﺟﺘﻤﺎﻋﻴﺔ‬
Please declare any of the below cases by marking P under the word Yes ‫ ﻓﻲ ﺍﻟﻤﺮﺑﻊ ﺗﺤﺖ ﻛﻠﻤﺔ ﻧﻌﻢ‬P ‫ﻳﺮﺟﻰ ﺍﻹﻓﺼﺎﺡ ﻋﻦ ﻭﺟﻮﺩ ﺃﻱ ﻣﻦ ﺍﻟﺤﺎﻻﺕ ﺍﺩﻧﺎﻩ ﺑﻮﺿﻊ ﺇﺷﺎﺭﺓ‬
"Below Undeclared Medical Case May Not Be Covered" No / ‫ﻻ‬ Yes / ‫ﻧﻌـﻢ‬ "‫"ﻟﻦ ﺗﺘﻢ ﺍﻟﺘﻐﻄﻴﺔ ﺍﻟﺘﺄﻣﻴﻨﻴﺔ ﻟﻠﺤﺎﻻﺕ ﺃﺩﻧﺎﻩ ﻓﻰ ﺣﺎﻝ ﻋﺪﻡ ﺍﻹﻓﺼﺎﺡ ﻋﻨﻬﺎ‬
Any hospital admission during last 12 months. ‫ ﺷﻬﺮ‬12 ‫ﻫﻞ ﺗﻢ ﺍﻟﺘﻨﻮﻳﻢ ﺑﺎﻟﻤﺴﺘﺸﻔﻰ ﺧﻼﻝ ﺃﺧﺮ‬
"Admission: registering as an admitted patient at the hospital until the following morning "
* * " ‫ ﺗﺴﺠﻴﻞ ﺍﻟﺸﺨﺺ ﺍﻟﻤﺆﻣﻦ ﻟﻪ ﻛﻤﺮﻳﺾ ﻣﻨﻮﻡ ﻓﻲ ﺍﻟﻤﺴﺘﺸﻔﻰ ﺣﺘﻰ ﺻﺒﺎﺡ ﺍﻟﻴﻮﻡ ﺍﻟﺘﺎﻟﻲ‬: ‫" ﺍﻟﺘﻨﻮﻳﻢ‬

Have you been diagnosed with any of the following chronic disease limited ‫ﻫﻞ ﺗﻢ ﺗﺸﺨﻴﺼﻚ ﺑﺄﻯ ﻣﻦ ﺍﻷﻣﺮﺍﺽ ﺍﻟﺘﺎﻟﻴﺔ ﻓﻘﻂ‬
to:Autism, listed Benign Tumor (Breast tumors, fibroid uterus, benign prostatic hyperplasia, ‫ﺃﻭﺭﺍﻡ ﺃﻭ‬,‫ﺗﻀﺨﻢ ﺍﻟﺒﺮﻭﺳﺘﺎﺗﺎ ﺍﻟﺤﻤﻴﺪ‬,‫ ﺃﻭﺭﺍﻡ ﺍﻟﺮﺣﻢ ﺍﻟﻠﻴﻔﻰ‬, ‫ﺍﻻﻭﺭﺍﻡ ﺍﻟﺤﻤﻴﺪﺓ ﺍﻟﺘﺎﻟﻴﺔ )ﺃﻭﺭﺍﻡ ﺍﻟﺜﺪﻯ‬,‫ﺍﻷﻭﺭﺍﻡ ﺍﻟﺴﺮﻃﺎﻧﻴﺔ‬,‫ﺍﻟﺘﻮﺣﺪ‬
thyroid goiter and parathyroid glands, live tumors, colon tumors). Malignant tumors, listed ‫ﺃﻣﺮﺍﺽ ﺍﻟﻘﻠﺐ ﺍﻟﺘﺎﻟﻴﺔ)ﺃﻣﺮﺍﺽ ﺷﺮﺍﻳﻴﻦ ﻭﺻﻤﺎﻣﺎﺕ ﺗﻀﺨﻢ ﺍﻟﻐﺪﺓ ﺍﻟﺪﺭﻗﻴﺔ‬, (‫ﺃﻭﺭﺍﻡ ﺍﻟﻘﻮﻟﻮﻥ‬, ‫ﻭﺃﻭﺭﺍﻡ ﺍﻻﻟﻜﺒﺪ‬,‫ﻭ ﺍﻟﺠﺎﺭ ﺍﻟﺪﺭﻗﻴﺔ‬
Cardiac diseases coronary and valve heart diseases, heart failure, cardiac fibrillation
myocardial infraction, heart clots). Chronic Hepatitis C. Gallstones Sever Kidney failure (stage
* * ‫ﺍﻻﻟﺘﻬﺎﺏ ﺍﻟﻜﺒﺪﻯ ﺍﻟﻔﻴﺮﻭﺳﻰ ﺍﻟﻤﺰﻣﻦ‬.( ‫ﺍﻟﺮﺟﻔﺎﻥ ﺍﻟﻘﻠﺒﻰ ﻭﺟﻠﻄﺎﺕ ﺍﻟﻘﻠﺐ‬, ‫ﻓﺸﻞ ﻋﻀﻠﺔ ﺍﻟﻘﻠﺐ‬, ‫ﺣﺼﻮﺍﺕ ﺍﻟﻤﺮﺍﺭﺓ ﺍﻟﻘﻠﺐ‬, ‫ﺝ ﻭﺳﻰ‬
,‫ ﺍﻟﺘﺮﺷﻴﺢ ﺍﻟﻜﻠﻮﻯ ﺃﻗﻞ ﻣﻦ‬,‫ ﺍﻟﻔﺸﻞ ﺍﻟﻜﻠﻮﻯﺍﻟﺸﺪﻳﺪ )ﺍﻟﻤﺮﺣﻠﺔ ﺍﻟﺨﺎﻣﺴﺔ ﻣﻦ ﺍﻣﺮﺍﺽ ﺍﻟﻜﻠﻰ ﺍﻟﺘﻰ ﺗﺴﺘﺪﻋﻰ ﺍﻟﻐﺴﻴﻞ ﺍﻟﻜﻠﻮﻯ‬15
5 Requiring dialysis, clearance of less tha 15 ml/ minute*). Urinary tract ‫ﻣﺮﺽ‬, ‫ﺩﻗﻴﻘﺔ(ﺣﺼﻮﺍﺕ ﺍﻟﻤﺴﺎﻟﻚ ﺍﻟﺒﻮﻟﻴﺔﺃﻣﺮﺍﺽ ﺍﻟﻤﻨﺎﻋﺔ ﺍﻟﺘﺎﻟﻴﺔ )ﺍﻟﺬﺋﺒﺔ ﺍﻟﺤﻤﺮﺍﺀﻭﺍﻟﺘﻬﺎﺏ ﺍﻟﻤﻔﺎﺻﻞ ﺍﻟﺮﻭﻣﺎﺗﻴﺰﻣﻴﺔﻭ ﺍﻟﺼﺪﻓﻴﺔ‬/‫ﻣﻞ‬
stones, hernias. Autoimmune disease (lupus, rheumatoid arthritis, psoriasis, Crohn's disease, ‫ﺍﻟﺘﻬﺎﺏ ﺍﻟﻘﻮﻟﻮﻥ ﺍﻟﺘﻘﺮﺣﻰ‬, ‫ﻛﺮﻭﻧﺰ‬,
ulcerative colitis,multiple sclerosis, celiac disease) ‫ﺣﺴﺎﺳﻴﺔ ﺍﻟﻘﻤﺢ‬, ‫ﺍﻟﺘﺼﻠﺐ ﺍﻟﻠﻮﻳﺤﻰ‬

Have you been diagnosed with any of the following congenital disorder or
hereditary diseases limited to: Cerebral palsy, Sickle cell disorder, Thalassemia, ‫ﻫﻞ ﺗﻢ ﺗﺸﺨﻴﺼﻚ ﺑﺄﻱ ﻣﻦ ﺍﻷﻣﺮﺍﺽ ﺍﻟﻮﺭﺍﺛﻴﺔ ﺃﻭ ﺍﻟﺘﺸﻮﻫﺎﺕ ﺍﻟﺨﻠﻘﻴﺔ ﺍﻟﺘﺎﻟﻴﺔ ﻓﻘﻂ‬
hemophilia, metabolic diseases, Hydrocephalus, spinal muscle atrophy, genital ‫ ﺿﻤﻮﺭ‬،‫ ﺃﺳﺘﺴﻘﺎﺀ ﺍﻟﺮﺃﺱ‬،‫ ﺃﻣﺮﺍﺽ ﺍﻟﺘﻤﺜﻴﻞ ﺍﻟﻐﺬﺍﺋﻲ‬،‫ ﺍﻟﻬﻴﻤﻮﻓﻴﻠﻴﺎ‬،‫ ﺍﻟﺘﻼﺳﻴﻤﻴﺎ‬،‫ﺍﺿﻄﺮﺍﺏ ﺍﻟﺨﻼﻳﺎ ﺍﻟﻤﻨﺠﻠﻴﺔ‬, ‫ﺍﻟﺸﻠﻞ ﺍﻟﺪﻣﺎﻏﻰ‬
malformations, chromosomal abnormalities. Gaucher's disease, G6PD Deficiency, cystic
fibrosis, hemochromatosis, Wilson disease. Polycystic Kidney Disease.
* * ‫ ﻣﺮﺽ ﺍﻟﺘﻜﺴﺮﺍﻟﻔﻮﻟﻰ‬،‫ ﻣﺮﺽ ﻏﻮﺷﺮ‬،‫ ﺃﻣﺮﺍﺽ ﺍﻟﻜﺮﻭﻣﻮﺳﻮﻣﺎﺕ‬،‫ ﺗﺸﻮﻫﺎﺕ ﺍﻷﻋﻀﺎﺀ ﺍﻟﺘﻨﺎﺳﻠﻴﺔ‬،‫ﺍﻟﻌﻀﻼﺕ ﺍﻟﺸﻮﻛﻲ‬
‫ﺗﻜﻴﺲ‬,‫ﻣﺮﺽ ﻭﻳﻠﺴﻮﻥ‬, (‫ ﻣﺮﺽ ﺗﻜﺪﺱ ﺍﻟﺤﺪﻳﺪ )ﻫﻴﻤﻮﻛﺮﻭﻣﺎﺗﻮﺳﻴﺲ‬،‫( ﺍﻟﺘﻠﻴﻒ ﺍﻟﻜﻴﺴﻲ ﻟﻠﺮﺋﺔ‬G6PD)
‫ﺍﻟﻜﻠﻴﺘﻴﻦ ﺍﻟﺨﻠﻔﻰ ﺍﻟﻮﺭﺍﺋﻰ‬

Have you been diagnosed with any of following eye diseases limited to: ،‫ ﻣﻴﺎﺓ ﺯﺭﻗﺎﺀ‬،‫ ﻣﻴﺎﺓ ﺑﻴﻀﺎﺀ‬:‫ﻫﻞ ﺗﻢ ﺗﺸﺨﻴﺼﻚ ﺑﺄﻱ ﻣﻦ ﺃﻣﺮﺍﺽ ﺍﻟﻌﻴﻦ ﺍﻟﺘﺎﻟﻴﺔ ﻓﻘﻂ‬
Cataract, Glaucoma, Retinal diseases. * * ‫ﺃﻣﺮﺍﺽ ﺍﻟﺸﺒﻜﻴﺔ‬
Have you been diagnosed with any of the following bone diseases limited ‫ ﺍﻹﻧﺰﻻﻕ ﺍﻟﻐﻀﺮﻭﻓﻲ‬:‫ﻫﻞ ﺗﻢ ﺗﺸﺨﻴﺼﻚ ﺑﺄﻱ ﻣﻦ ﺃﻣﺮﺍﺽ ﺍﻟﻌﻈﺎﻡ ﺍﻟﺘﺎﻟﻴﺔ ﻓﻘﻂ‬
to:Vertebral disc prolapse (moderate or severe), Scoliosis (moderate or severe)**, or ligament
tears, osteoarthritis (moderate or severe )
* * ‫ﺗﻤﺰﻕ ﺍﻷﺭﺑﻄﺔ‬،‫ﺍﻟﺘﻬﺎﺏ ﺍﻟﻤﻔﺎﺻﻞ‬،‫ﺇﻧﺤﺮﺍﻑ ﺍﻟﻌﻤﻮﺩ ﺍﻟﻔﻘﺮﻱ‬,‫ﺍﻟﺪﻳﺴﻚ‬

Pregnant Female Only ‫ﻟﻸﻧﺜﻰ ﺍﻟﺤﺎﻣﻞ ﻓﻘﻂ‬

‫ﺣﻤﻞ ﺣﺎﻟﻲ ﺟﻨﻴﻦ ﻭﺍﺣﺪ‬
Current Single Pregnancy
* *
‫ﺣﻤﻞ ﺣﺎﻟﻲ ﻣﻊ ﻗﻴﺼﺮﻳﺔ ﺳﺎﺑﻘﺔ‬
Current Single Pregnancy with Previous CS Delivery
* *
‫ﺣﻤﻞ ﺣﺎﻟﻲ ﻣﺘﻌﺪﺩ ﺍﻷﺟﻨﺔ‬
Current Multiple Pregnancy
* *
Expected delivery date .. / .. / .... ‫ﺗﺎﺭﻳﺦ ﺍﻟﻮﻻﺩﺓ ﺍﻟﻤﺘﻮﻗﻊ‬
Employee and dependents details that need to be added ‫ﺑﻴﺎﻧﺎﺕ ﺍﻟﻤﻮﻇﻒ ﻭﺃﻓﺮﺍﺩ ﺍﻟﻌﺎﺋﻠﺔ ﺍﻟﻤﺮﺍﺩ ﺇﺿﺎﻓﺘﻬﻢ‬
In case of a yes answer above, please declare the case in the table below ‫ ﺍﻟﺮﺟﺎﺀ ﺫﻛﺮ ﺍﻟﺤﺎﻟﺔ ﻓﻲ ﺍﻟﺠﺪﻭﻝ ﺃﺩﻧﺎﻩ‬،‫ﻓﻲ ﺣﺎﻟﺔ ﺍﻹﺟﺎﺑﺔ ﺑﻨﻌﻢ ﺃﻋﻼﻩ‬
‫ﺇﺳﻢ ﻣﻘﺪﻡ ﺍﻟﺨﺪﻣﺔ‬ ‫ﺍﻟﺤﺎﻟﺔ‬ ‫ﺭﻗﻢ ﺍﻟﺠﻮﺍﻝ‬ ‫ﺍﻟﻄﻮﻝ‬ ‫ﺍﻟﻮﺯﻥ‬ ‫ﺭﻗﻢ ﺍﻟﻬﻮﻳﺔ‬ ‫ﺍﻟﻘﺮﺍﺑﺔ‬ ‫ﺍﻟﺠﻨﺲ‬ ‫ ﺃﻓﺮﺍﺩ ﺍﻟﻌﺎﺋﻠﺔ‬/ ‫ﺍﺳﻢ ﺍﻟﻤﻮﻇﻒ‬ ‫ﻡ‬
2477665323 Child Male / ‫ ﺫﻛﺮ‬Hamdan Mohammed Khaliq U 1
2
3
4
5
Undertakings : ‫ﺍﻹﻗﺮﺍﺭ ﻭﺍﻟﺘﻔﻮﻳﺾ‬
1- I hereby undertake that all the above information is correct and the acceptance of my ‫ﻭﺍﻟﻤﻌﻠﻮﻣﺎﺕ ﺍﻟﻤﺬﻛﻮﺭﺓ ﺃﻋﻼﻩ ﻛﺎﻣﻠﺔ ﻭﺻﺤﻴﺤﺔ ﻭﺑﻨﺎﺀ ﻋﻠﻴﻪ ﻓﺈﻥ ﻗﺒﻮﻝ ﺍﻟﻄﻠﺐ ﺳﻴﺘﻢ‬: ‫ ﺃﻗﺮ ﺃﻥ ﺍﻟﺒﻴﺎﻧﺎﺕ‬-1
enrollment will be on the basis of such information and that Malath Cooperative Insurance ‫ﻋﻠﻰ ﺃﺳﺎﺱ ﻫﺬﻩ ﺍﻟﺒﻴﺎﻧﺎﺕ ﻭﺃﻥ ﺷﺮﻛﺔ ﻣﻼﺫ ﻟﻠﺘﺄﻣﻴﻦ ﺍﻟﺘﻌﺎﻭﻧﻲ ﻟﻬﺎ ﺍﻟﺤﻖ ﻓﻲ ﺍﻻﺗﺼﺎﻝ ﺑﺎﻟﻤﺴﺘﺸﻔﻴﺎﺕ ﺍﻟﺘﻲ‬
Company has the right to contact the hospital(s) I deal with to collect any ‫ﺃﺗﻌﺎﻣﻞ ﻣﻌﻬﺎ ﻟﺘﺰﻭﻳﺪﻫﺎ ﺑﺄﻱ ﻣﻌﻠﻮﻣﺎﺕ ﻃﺒﻴﺔ ﻗﺪ ﺗﺤﺘﺎﺝ ﺇﻟﻴﻬﺎ ﻟﺘﻘﻴﻴﻢ ﺍﻟﻤﺨﺎﻃﺮ‬
medical information needed to assess the risk(s).

2- I agree that Malath Cooperative Insurance Company has the right to reject the ‫ ﺃﻭﺍﻓﻖ ﻋﻠﻰ ﺃﺣﻘﻴﺔ ﺷﺮﻛﺔ ﻣﻼﺫ ﻟﻠﺘﺄﻣﻴﻦ ﻓﻲ ﺭﻓﺾ ﺍﻟﻤﻄﺎﻟﺒﺔ ﺃﻭ ﺍﻟﺘﻐﻄﻴﺔ ﻛﻠﻴﺎ ﻋﻨﺪ ﻋﺪﻡ ﺍﻹﻓﺼﺎﺡ ﻋﻦ ﻭﺟﻮﺩ ﺃﻱ ﻣﻦ ﺍﻟﺤﺎﻻﺕ‬-2
coverage/claims in full in case of no declaration of any cases prior to the contractual date or ‫ﺍﻟﻤﺬﻛﻮﺭﺓ ﺃﻋﻼﻩ ﺍﻟﺘﻲ ﻧﺸﺄﺕ ﻗﺒﻞ ﺗﺎﺭﻳﺦ ﺍﻟﺘﻌﺎﻗﺪ ﺃﻭ ﻗﺒﻞ ﺗﺴﺠﻴﻞ ﺃﻭ ﺇﺿﺎﻓﺔ ﻋﻀﻮ ﺧﻼﻝ ﻓﺘﺮﺓ ﺳﺮﻳﺎﻥ ﺍﻟﻌﻘﺪ‬
before enrolling or adding a new member during the contract.

3- I hereby confirm reading and understanding all points presented in this form and I agree that ‫ ﺃﻗﺮﺑﺄﻧﻲ ﻗﺪ ﻗﺮﺃﺕ ﻭﻓﻬﻤﺖ ﺟﻤﻴﻊ ﻣﺎ ﺟﺎﺀ ﻓﻲ ﻫﺬﺍ ﺍﻟﻨﻤﻮﺫﺝ ﻛﻤﺎ ﺃﺗﻌﻬﺪ ﺑﺄﻥ ﻋﺪﻡ ﺇﺷﺎﺭﺗﻲ ﺃﻣﺎﻡ ﺃﻱ ﻣﻦ‬-3
not marking any case is understood as “Nothing requires declaration” and I sign on these ‫ﺍﻟﺤﺎﻻﺕ ﺍﻟﻤﺬﻛﻮﺭﺓ ﺃﻋﻼﻩ ﻳﻌﺘﺒﺮ ﺑﻤﺜﺎﺑﺔ ﻧﻔﻲ ﻭﺟﻮﺩ ﻣﺎﻳﺴﺘﺤﻖ ﺍﻹﻓﺼﺎﺡ ﻋﻨﻪ ﻭﻋﻠﻴﻪ ﺃﻭﻗﻊ‬
basis.
4- Failure to fill the weight and height information will result in refusal to cover
the cost of obesity surgery. ‫ ﻋﺪﻡ ﺗﻌﺒﺌﺔ ﺑﻴﺎﻧﺎﺕ ﺍﻟﻄﻮﻝ ﻭﺍﻟﻮﺯﻥ ﺳﻴﺆﺩﻱ ﺇﻟﻰ ﺭﻓﺾ ﺗﻐﻄﻴﺔ ﺗﻜﺎﻟﻴﻒ ﻋﻤﻠﻴﺔ ﺟﺮﺍﺣﺔ ﺍﻟﺴﻤﻨﺔ ﺍﻟﻤﻔﺮﻃﺔ‬-4

Entity's stamp ‫ﺧﺘﻢ ﺟﻬﺔ ﺍﻟﻌﻤﻞ‬ Insured Signature ‫ﺗﻮﻗﻴﻊ ﺍﻟﻤﻮﻇﻒ‬ Date ‫ﺍﻟﺘﺎﺭﻳﺦ‬
.. / .. / ....

New_Health_Insurance.rdf Page 15 of 39 V.20 13-DEC-2023 01:30 PM

 ‫ﻧﻤﻮﺫﺝ ﺍﻻﻓﺼﺎﺡ ﺍﻟﻄﺒﻲ ﺍﻟﻤﻮﺣﺪ‬
Unified Medical Declaration Form
Product Code: A-MLTH-2-C-08-014
Dear Insured: ‫ﻋﺰﻳﺰﻱ ﺍﻟﻤﺆﻣﻦ ﻟﻪ‬
Please Fill out the form correctly for the purpose of pricing and to ensured that you and your ‫ﻧﺄﻣﻞ ﻗﻴﺎﻣﻚ ﺑﺘﻌﺒﺌﺔ ﻫﺬﺍ ﺍﻟﻨﻤﻮﺫﺝ ﺑﺎﻟﺸﻜﻞ ﺍﻟﺼﺤﻴﺢ ﻟﻐﺮﺽ ﺍﻟﺘﺴﻌﻴﺮ ﻭﻟﻀﻤﺎﻥ ﺣﺼﻮﻟﻚ ﻭﺃﻓﺮﺍﺩ ﺃﺳﺮﺗﻚ ﻋﻠﻰ ﺧﺪﻣﺎﺕ‬
family receive health care services as required according to your unfied policy benefit ‫ﺍﻟﺮﻋﺎﻳﺔ ﺍﻟﺼﺤﻴﺔ ﺑﺎﻟﺸﻜﻞ ﺍﻟﻤﻄﻠﻮﺏ ﺣﺴﺐ ﻣﻨﺎﻓﻊ ﺍﻟﻮﺛﻴﻘﺔ ﺍﻟﻤﻮﺣﺪﺓ‬

Addition ‫ﺇﺿﺎﻓﺔ‬ New ‫ﺟﺪﻳﺪ‬ Type ‫ﻧﻮﻉ ﺍﻟﻄﻠﺐ‬

CR No 7011507360 ‫ﺍﻟﺴﺠﻞ ﺍﻟﺘﺠﺎﺭﻱ‬ Entity Name HADDAJ AL HIJAZ EST ‫ﺃﺳﻢ ﺍﻟﻤﻨﺸﺄﺓ‬
Mobile No 0568551650 ‫ﺭﻗﻢ ﺍﻟﺠﻮﺍﻝ‬ Ahmad Khaliqullah ‫ﺍﺳﻢ ﺍﻟﻤﻮﻇﻒ‬
ID Number 2 0 1 6 7 6 8 6 6 1 ‫ﺭﻗﻢ ﺍﻟﻬﻮﻳﺔ‬
Male / ‫ﺫﻛﺮ‬ India
Gender ‫ ﺍﻟﺠﻨﺲ‬Nationality ‫ ﺍﻟﺠﻨﺴﻴﺔ‬Marital status Married R ‫ﻣﺘﺰﻭﺝ‬ Single * ‫ﺃﻋﺰﺏ‬ ‫ﺍﻟﺤﺎﻟﺔ ﺍﻻﺟﺘﻤﺎﻋﻴﺔ‬
Please declare any of the below cases by marking P under the word Yes ‫ ﻓﻲ ﺍﻟﻤﺮﺑﻊ ﺗﺤﺖ ﻛﻠﻤﺔ ﻧﻌﻢ‬P ‫ﻳﺮﺟﻰ ﺍﻹﻓﺼﺎﺡ ﻋﻦ ﻭﺟﻮﺩ ﺃﻱ ﻣﻦ ﺍﻟﺤﺎﻻﺕ ﺍﺩﻧﺎﻩ ﺑﻮﺿﻊ ﺇﺷﺎﺭﺓ‬
"Below Undeclared Medical Case May Not Be Covered" No / ‫ﻻ‬ Yes / ‫ﻧﻌـﻢ‬ "‫"ﻟﻦ ﺗﺘﻢ ﺍﻟﺘﻐﻄﻴﺔ ﺍﻟﺘﺄﻣﻴﻨﻴﺔ ﻟﻠﺤﺎﻻﺕ ﺃﺩﻧﺎﻩ ﻓﻰ ﺣﺎﻝ ﻋﺪﻡ ﺍﻹﻓﺼﺎﺡ ﻋﻨﻬﺎ‬
Any hospital admission during last 12 months. ‫ ﺷﻬﺮ‬12 ‫ﻫﻞ ﺗﻢ ﺍﻟﺘﻨﻮﻳﻢ ﺑﺎﻟﻤﺴﺘﺸﻔﻰ ﺧﻼﻝ ﺃﺧﺮ‬
"Admission: registering as an admitted patient at the hospital until the following morning "
* * " ‫ ﺗﺴﺠﻴﻞ ﺍﻟﺸﺨﺺ ﺍﻟﻤﺆﻣﻦ ﻟﻪ ﻛﻤﺮﻳﺾ ﻣﻨﻮﻡ ﻓﻲ ﺍﻟﻤﺴﺘﺸﻔﻰ ﺣﺘﻰ ﺻﺒﺎﺡ ﺍﻟﻴﻮﻡ ﺍﻟﺘﺎﻟﻲ‬: ‫" ﺍﻟﺘﻨﻮﻳﻢ‬

Have you been diagnosed with any of the following chronic disease limited ‫ﻫﻞ ﺗﻢ ﺗﺸﺨﻴﺼﻚ ﺑﺄﻯ ﻣﻦ ﺍﻷﻣﺮﺍﺽ ﺍﻟﺘﺎﻟﻴﺔ ﻓﻘﻂ‬
to:Autism, listed Benign Tumor (Breast tumors, fibroid uterus, benign prostatic hyperplasia, ‫ﺃﻭﺭﺍﻡ ﺃﻭ‬,‫ﺗﻀﺨﻢ ﺍﻟﺒﺮﻭﺳﺘﺎﺗﺎ ﺍﻟﺤﻤﻴﺪ‬,‫ ﺃﻭﺭﺍﻡ ﺍﻟﺮﺣﻢ ﺍﻟﻠﻴﻔﻰ‬, ‫ﺍﻻﻭﺭﺍﻡ ﺍﻟﺤﻤﻴﺪﺓ ﺍﻟﺘﺎﻟﻴﺔ )ﺃﻭﺭﺍﻡ ﺍﻟﺜﺪﻯ‬,‫ﺍﻷﻭﺭﺍﻡ ﺍﻟﺴﺮﻃﺎﻧﻴﺔ‬,‫ﺍﻟﺘﻮﺣﺪ‬
thyroid goiter and parathyroid glands, live tumors, colon tumors). Malignant tumors, listed ‫ﺃﻣﺮﺍﺽ ﺍﻟﻘﻠﺐ ﺍﻟﺘﺎﻟﻴﺔ)ﺃﻣﺮﺍﺽ ﺷﺮﺍﻳﻴﻦ ﻭﺻﻤﺎﻣﺎﺕ ﺗﻀﺨﻢ ﺍﻟﻐﺪﺓ ﺍﻟﺪﺭﻗﻴﺔ‬, (‫ﺃﻭﺭﺍﻡ ﺍﻟﻘﻮﻟﻮﻥ‬, ‫ﻭﺃﻭﺭﺍﻡ ﺍﻻﻟﻜﺒﺪ‬,‫ﻭ ﺍﻟﺠﺎﺭ ﺍﻟﺪﺭﻗﻴﺔ‬
Cardiac diseases coronary and valve heart diseases, heart failure, cardiac fibrillation
myocardial infraction, heart clots). Chronic Hepatitis C. Gallstones Sever Kidney failure (stage
* * ‫ﺍﻻﻟﺘﻬﺎﺏ ﺍﻟﻜﺒﺪﻯ ﺍﻟﻔﻴﺮﻭﺳﻰ ﺍﻟﻤﺰﻣﻦ‬.( ‫ﺍﻟﺮﺟﻔﺎﻥ ﺍﻟﻘﻠﺒﻰ ﻭﺟﻠﻄﺎﺕ ﺍﻟﻘﻠﺐ‬, ‫ﻓﺸﻞ ﻋﻀﻠﺔ ﺍﻟﻘﻠﺐ‬, ‫ﺣﺼﻮﺍﺕ ﺍﻟﻤﺮﺍﺭﺓ ﺍﻟﻘﻠﺐ‬, ‫ﺝ ﻭﺳﻰ‬
,‫ ﺍﻟﺘﺮﺷﻴﺢ ﺍﻟﻜﻠﻮﻯ ﺃﻗﻞ ﻣﻦ‬,‫ ﺍﻟﻔﺸﻞ ﺍﻟﻜﻠﻮﻯﺍﻟﺸﺪﻳﺪ )ﺍﻟﻤﺮﺣﻠﺔ ﺍﻟﺨﺎﻣﺴﺔ ﻣﻦ ﺍﻣﺮﺍﺽ ﺍﻟﻜﻠﻰ ﺍﻟﺘﻰ ﺗﺴﺘﺪﻋﻰ ﺍﻟﻐﺴﻴﻞ ﺍﻟﻜﻠﻮﻯ‬15
5 Requiring dialysis, clearance of less tha 15 ml/ minute*). Urinary tract ‫ﻣﺮﺽ‬, ‫ﺩﻗﻴﻘﺔ(ﺣﺼﻮﺍﺕ ﺍﻟﻤﺴﺎﻟﻚ ﺍﻟﺒﻮﻟﻴﺔﺃﻣﺮﺍﺽ ﺍﻟﻤﻨﺎﻋﺔ ﺍﻟﺘﺎﻟﻴﺔ )ﺍﻟﺬﺋﺒﺔ ﺍﻟﺤﻤﺮﺍﺀﻭﺍﻟﺘﻬﺎﺏ ﺍﻟﻤﻔﺎﺻﻞ ﺍﻟﺮﻭﻣﺎﺗﻴﺰﻣﻴﺔﻭ ﺍﻟﺼﺪﻓﻴﺔ‬/‫ﻣﻞ‬
stones, hernias. Autoimmune disease (lupus, rheumatoid arthritis, psoriasis, Crohn's disease, ‫ﺍﻟﺘﻬﺎﺏ ﺍﻟﻘﻮﻟﻮﻥ ﺍﻟﺘﻘﺮﺣﻰ‬, ‫ﻛﺮﻭﻧﺰ‬,
ulcerative colitis,multiple sclerosis, celiac disease) ‫ﺣﺴﺎﺳﻴﺔ ﺍﻟﻘﻤﺢ‬, ‫ﺍﻟﺘﺼﻠﺐ ﺍﻟﻠﻮﻳﺤﻰ‬

Have you been diagnosed with any of the following congenital disorder or
hereditary diseases limited to: Cerebral palsy, Sickle cell disorder, Thalassemia, ‫ﻫﻞ ﺗﻢ ﺗﺸﺨﻴﺼﻚ ﺑﺄﻱ ﻣﻦ ﺍﻷﻣﺮﺍﺽ ﺍﻟﻮﺭﺍﺛﻴﺔ ﺃﻭ ﺍﻟﺘﺸﻮﻫﺎﺕ ﺍﻟﺨﻠﻘﻴﺔ ﺍﻟﺘﺎﻟﻴﺔ ﻓﻘﻂ‬
hemophilia, metabolic diseases, Hydrocephalus, spinal muscle atrophy, genital ‫ ﺿﻤﻮﺭ‬،‫ ﺃﺳﺘﺴﻘﺎﺀ ﺍﻟﺮﺃﺱ‬،‫ ﺃﻣﺮﺍﺽ ﺍﻟﺘﻤﺜﻴﻞ ﺍﻟﻐﺬﺍﺋﻲ‬،‫ ﺍﻟﻬﻴﻤﻮﻓﻴﻠﻴﺎ‬،‫ ﺍﻟﺘﻼﺳﻴﻤﻴﺎ‬،‫ﺍﺿﻄﺮﺍﺏ ﺍﻟﺨﻼﻳﺎ ﺍﻟﻤﻨﺠﻠﻴﺔ‬, ‫ﺍﻟﺸﻠﻞ ﺍﻟﺪﻣﺎﻏﻰ‬
malformations, chromosomal abnormalities. Gaucher's disease, G6PD Deficiency, cystic
fibrosis, hemochromatosis, Wilson disease. Polycystic Kidney Disease.
* * ‫ ﻣﺮﺽ ﺍﻟﺘﻜﺴﺮﺍﻟﻔﻮﻟﻰ‬،‫ ﻣﺮﺽ ﻏﻮﺷﺮ‬،‫ ﺃﻣﺮﺍﺽ ﺍﻟﻜﺮﻭﻣﻮﺳﻮﻣﺎﺕ‬،‫ ﺗﺸﻮﻫﺎﺕ ﺍﻷﻋﻀﺎﺀ ﺍﻟﺘﻨﺎﺳﻠﻴﺔ‬،‫ﺍﻟﻌﻀﻼﺕ ﺍﻟﺸﻮﻛﻲ‬
‫ﺗﻜﻴﺲ‬,‫ﻣﺮﺽ ﻭﻳﻠﺴﻮﻥ‬, (‫ ﻣﺮﺽ ﺗﻜﺪﺱ ﺍﻟﺤﺪﻳﺪ )ﻫﻴﻤﻮﻛﺮﻭﻣﺎﺗﻮﺳﻴﺲ‬،‫( ﺍﻟﺘﻠﻴﻒ ﺍﻟﻜﻴﺴﻲ ﻟﻠﺮﺋﺔ‬G6PD)
‫ﺍﻟﻜﻠﻴﺘﻴﻦ ﺍﻟﺨﻠﻔﻰ ﺍﻟﻮﺭﺍﺋﻰ‬

Have you been diagnosed with any of following eye diseases limited to: ،‫ ﻣﻴﺎﺓ ﺯﺭﻗﺎﺀ‬،‫ ﻣﻴﺎﺓ ﺑﻴﻀﺎﺀ‬:‫ﻫﻞ ﺗﻢ ﺗﺸﺨﻴﺼﻚ ﺑﺄﻱ ﻣﻦ ﺃﻣﺮﺍﺽ ﺍﻟﻌﻴﻦ ﺍﻟﺘﺎﻟﻴﺔ ﻓﻘﻂ‬
Cataract, Glaucoma, Retinal diseases. * * ‫ﺃﻣﺮﺍﺽ ﺍﻟﺸﺒﻜﻴﺔ‬
Have you been diagnosed with any of the following bone diseases limited ‫ ﺍﻹﻧﺰﻻﻕ ﺍﻟﻐﻀﺮﻭﻓﻲ‬:‫ﻫﻞ ﺗﻢ ﺗﺸﺨﻴﺼﻚ ﺑﺄﻱ ﻣﻦ ﺃﻣﺮﺍﺽ ﺍﻟﻌﻈﺎﻡ ﺍﻟﺘﺎﻟﻴﺔ ﻓﻘﻂ‬
to:Vertebral disc prolapse (moderate or severe), Scoliosis (moderate or severe)**, or ligament
tears, osteoarthritis (moderate or severe )
* * ‫ﺗﻤﺰﻕ ﺍﻷﺭﺑﻄﺔ‬،‫ﺍﻟﺘﻬﺎﺏ ﺍﻟﻤﻔﺎﺻﻞ‬،‫ﺇﻧﺤﺮﺍﻑ ﺍﻟﻌﻤﻮﺩ ﺍﻟﻔﻘﺮﻱ‬,‫ﺍﻟﺪﻳﺴﻚ‬

Pregnant Female Only ‫ﻟﻸﻧﺜﻰ ﺍﻟﺤﺎﻣﻞ ﻓﻘﻂ‬

‫ﺣﻤﻞ ﺣﺎﻟﻲ ﺟﻨﻴﻦ ﻭﺍﺣﺪ‬
Current Single Pregnancy
* *
‫ﺣﻤﻞ ﺣﺎﻟﻲ ﻣﻊ ﻗﻴﺼﺮﻳﺔ ﺳﺎﺑﻘﺔ‬
Current Single Pregnancy with Previous CS Delivery
* *
‫ﺣﻤﻞ ﺣﺎﻟﻲ ﻣﺘﻌﺪﺩ ﺍﻷﺟﻨﺔ‬
Current Multiple Pregnancy
* *
Expected delivery date .. / .. / .... ‫ﺗﺎﺭﻳﺦ ﺍﻟﻮﻻﺩﺓ ﺍﻟﻤﺘﻮﻗﻊ‬
Employee and dependents details that need to be added ‫ﺑﻴﺎﻧﺎﺕ ﺍﻟﻤﻮﻇﻒ ﻭﺃﻓﺮﺍﺩ ﺍﻟﻌﺎﺋﻠﺔ ﺍﻟﻤﺮﺍﺩ ﺇﺿﺎﻓﺘﻬﻢ‬
In case of a yes answer above, please declare the case in the table below ‫ ﺍﻟﺮﺟﺎﺀ ﺫﻛﺮ ﺍﻟﺤﺎﻟﺔ ﻓﻲ ﺍﻟﺠﺪﻭﻝ ﺃﺩﻧﺎﻩ‬،‫ﻓﻲ ﺣﺎﻟﺔ ﺍﻹﺟﺎﺑﺔ ﺑﻨﻌﻢ ﺃﻋﻼﻩ‬
‫ﺇﺳﻢ ﻣﻘﺪﻡ ﺍﻟﺨﺪﻣﺔ‬ ‫ﺍﻟﺤﺎﻟﺔ‬ ‫ﺭﻗﻢ ﺍﻟﺠﻮﺍﻝ‬ ‫ﺍﻟﻄﻮﻝ‬ ‫ﺍﻟﻮﺯﻥ‬ ‫ﺭﻗﻢ ﺍﻟﻬﻮﻳﺔ‬ ‫ﺍﻟﻘﺮﺍﺑﺔ‬ ‫ﺍﻟﺠﻨﺲ‬ ‫ ﺃﻓﺮﺍﺩ ﺍﻟﻌﺎﺋﻠﺔ‬/ ‫ﺍﺳﻢ ﺍﻟﻤﻮﻇﻒ‬ ‫ﻡ‬
2016768661 Employee Male / ‫ ﺫﻛﺮ‬Ahmad Khaliqullah 1
2
3
4
5
Undertakings : ‫ﺍﻹﻗﺮﺍﺭ ﻭﺍﻟﺘﻔﻮﻳﺾ‬
1- I hereby undertake that all the above information is correct and the acceptance of my ‫ﻭﺍﻟﻤﻌﻠﻮﻣﺎﺕ ﺍﻟﻤﺬﻛﻮﺭﺓ ﺃﻋﻼﻩ ﻛﺎﻣﻠﺔ ﻭﺻﺤﻴﺤﺔ ﻭﺑﻨﺎﺀ ﻋﻠﻴﻪ ﻓﺈﻥ ﻗﺒﻮﻝ ﺍﻟﻄﻠﺐ ﺳﻴﺘﻢ‬: ‫ ﺃﻗﺮ ﺃﻥ ﺍﻟﺒﻴﺎﻧﺎﺕ‬-1
enrollment will be on the basis of such information and that Malath Cooperative Insurance ‫ﻋﻠﻰ ﺃﺳﺎﺱ ﻫﺬﻩ ﺍﻟﺒﻴﺎﻧﺎﺕ ﻭﺃﻥ ﺷﺮﻛﺔ ﻣﻼﺫ ﻟﻠﺘﺄﻣﻴﻦ ﺍﻟﺘﻌﺎﻭﻧﻲ ﻟﻬﺎ ﺍﻟﺤﻖ ﻓﻲ ﺍﻻﺗﺼﺎﻝ ﺑﺎﻟﻤﺴﺘﺸﻔﻴﺎﺕ ﺍﻟﺘﻲ‬
Company has the right to contact the hospital(s) I deal with to collect any ‫ﺃﺗﻌﺎﻣﻞ ﻣﻌﻬﺎ ﻟﺘﺰﻭﻳﺪﻫﺎ ﺑﺄﻱ ﻣﻌﻠﻮﻣﺎﺕ ﻃﺒﻴﺔ ﻗﺪ ﺗﺤﺘﺎﺝ ﺇﻟﻴﻬﺎ ﻟﺘﻘﻴﻴﻢ ﺍﻟﻤﺨﺎﻃﺮ‬
medical information needed to assess the risk(s).

2- I agree that Malath Cooperative Insurance Company has the right to reject the ‫ ﺃﻭﺍﻓﻖ ﻋﻠﻰ ﺃﺣﻘﻴﺔ ﺷﺮﻛﺔ ﻣﻼﺫ ﻟﻠﺘﺄﻣﻴﻦ ﻓﻲ ﺭﻓﺾ ﺍﻟﻤﻄﺎﻟﺒﺔ ﺃﻭ ﺍﻟﺘﻐﻄﻴﺔ ﻛﻠﻴﺎ ﻋﻨﺪ ﻋﺪﻡ ﺍﻹﻓﺼﺎﺡ ﻋﻦ ﻭﺟﻮﺩ ﺃﻱ ﻣﻦ ﺍﻟﺤﺎﻻﺕ‬-2
coverage/claims in full in case of no declaration of any cases prior to the contractual date or ‫ﺍﻟﻤﺬﻛﻮﺭﺓ ﺃﻋﻼﻩ ﺍﻟﺘﻲ ﻧﺸﺄﺕ ﻗﺒﻞ ﺗﺎﺭﻳﺦ ﺍﻟﺘﻌﺎﻗﺪ ﺃﻭ ﻗﺒﻞ ﺗﺴﺠﻴﻞ ﺃﻭ ﺇﺿﺎﻓﺔ ﻋﻀﻮ ﺧﻼﻝ ﻓﺘﺮﺓ ﺳﺮﻳﺎﻥ ﺍﻟﻌﻘﺪ‬
before enrolling or adding a new member during the contract.

3- I hereby confirm reading and understanding all points presented in this form and I agree that ‫ ﺃﻗﺮﺑﺄﻧﻲ ﻗﺪ ﻗﺮﺃﺕ ﻭﻓﻬﻤﺖ ﺟﻤﻴﻊ ﻣﺎ ﺟﺎﺀ ﻓﻲ ﻫﺬﺍ ﺍﻟﻨﻤﻮﺫﺝ ﻛﻤﺎ ﺃﺗﻌﻬﺪ ﺑﺄﻥ ﻋﺪﻡ ﺇﺷﺎﺭﺗﻲ ﺃﻣﺎﻡ ﺃﻱ ﻣﻦ‬-3
not marking any case is understood as “Nothing requires declaration” and I sign on these ‫ﺍﻟﺤﺎﻻﺕ ﺍﻟﻤﺬﻛﻮﺭﺓ ﺃﻋﻼﻩ ﻳﻌﺘﺒﺮ ﺑﻤﺜﺎﺑﺔ ﻧﻔﻲ ﻭﺟﻮﺩ ﻣﺎﻳﺴﺘﺤﻖ ﺍﻹﻓﺼﺎﺡ ﻋﻨﻪ ﻭﻋﻠﻴﻪ ﺃﻭﻗﻊ‬
basis.
4- Failure to fill the weight and height information will result in refusal to cover
the cost of obesity surgery. ‫ ﻋﺪﻡ ﺗﻌﺒﺌﺔ ﺑﻴﺎﻧﺎﺕ ﺍﻟﻄﻮﻝ ﻭﺍﻟﻮﺯﻥ ﺳﻴﺆﺩﻱ ﺇﻟﻰ ﺭﻓﺾ ﺗﻐﻄﻴﺔ ﺗﻜﺎﻟﻴﻒ ﻋﻤﻠﻴﺔ ﺟﺮﺍﺣﺔ ﺍﻟﺴﻤﻨﺔ ﺍﻟﻤﻔﺮﻃﺔ‬-4

Entity's stamp ‫ﺧﺘﻢ ﺟﻬﺔ ﺍﻟﻌﻤﻞ‬ Insured Signature ‫ﺗﻮﻗﻴﻊ ﺍﻟﻤﻮﻇﻒ‬ Date ‫ﺍﻟﺘﺎﺭﻳﺦ‬
.. / .. / ....

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 ‫ﻧﻤﻮﺫﺝ ﺍﻻﻓﺼﺎﺡ ﺍﻟﻄﺒﻲ ﺍﻟﻤﻮﺣﺪ‬
Unified Medical Declaration Form
Product Code: A-MLTH-2-C-08-014
Dear Insured: ‫ﻋﺰﻳﺰﻱ ﺍﻟﻤﺆﻣﻦ ﻟﻪ‬
Please Fill out the form correctly for the purpose of pricing and to ensured that you and your ‫ﻧﺄﻣﻞ ﻗﻴﺎﻣﻚ ﺑﺘﻌﺒﺌﺔ ﻫﺬﺍ ﺍﻟﻨﻤﻮﺫﺝ ﺑﺎﻟﺸﻜﻞ ﺍﻟﺼﺤﻴﺢ ﻟﻐﺮﺽ ﺍﻟﺘﺴﻌﻴﺮ ﻭﻟﻀﻤﺎﻥ ﺣﺼﻮﻟﻚ ﻭﺃﻓﺮﺍﺩ ﺃﺳﺮﺗﻚ ﻋﻠﻰ ﺧﺪﻣﺎﺕ‬
family receive health care services as required according to your unfied policy benefit ‫ﺍﻟﺮﻋﺎﻳﺔ ﺍﻟﺼﺤﻴﺔ ﺑﺎﻟﺸﻜﻞ ﺍﻟﻤﻄﻠﻮﺏ ﺣﺴﺐ ﻣﻨﺎﻓﻊ ﺍﻟﻮﺛﻴﻘﺔ ﺍﻟﻤﻮﺣﺪﺓ‬

Addition ‫ﺇﺿﺎﻓﺔ‬ New ‫ﺟﺪﻳﺪ‬ Type ‫ﻧﻮﻉ ﺍﻟﻄﻠﺐ‬

CR No 7011507360 ‫ﺍﻟﺴﺠﻞ ﺍﻟﺘﺠﺎﺭﻱ‬ Entity Name HADDAJ AL HIJAZ EST ‫ﺃﺳﻢ ﺍﻟﻤﻨﺸﺄﺓ‬
Mobile No 0536441343 ‫ﺭﻗﻢ ﺍﻟﺠﻮﺍﻝ‬ Ayesha Sharif Ahmed Khan ‫ﺍﺳﻢ ﺍﻟﻤﻮﻇﻒ‬
ID Number 2 3 5 8 3 3 1 2 5 0 ‫ﺭﻗﻢ ﺍﻟﻬﻮﻳﺔ‬
Gender Female / ‫ﺍﻟﺠﻨﺲ ﺃﻧﺜﻰ‬ Nationality India ‫ ﺍﻟﺠﻨﺴﻴﺔ‬Marital status Married R ‫ﻣﺘﺰﻭﺝ‬ Single * ‫ﺃﻋﺰﺏ‬ ‫ﺍﻟﺤﺎﻟﺔ ﺍﻻﺟﺘﻤﺎﻋﻴﺔ‬
Please declare any of the below cases by marking P under the word Yes ‫ ﻓﻲ ﺍﻟﻤﺮﺑﻊ ﺗﺤﺖ ﻛﻠﻤﺔ ﻧﻌﻢ‬P ‫ﻳﺮﺟﻰ ﺍﻹﻓﺼﺎﺡ ﻋﻦ ﻭﺟﻮﺩ ﺃﻱ ﻣﻦ ﺍﻟﺤﺎﻻﺕ ﺍﺩﻧﺎﻩ ﺑﻮﺿﻊ ﺇﺷﺎﺭﺓ‬
"Below Undeclared Medical Case May Not Be Covered" No / ‫ﻻ‬ Yes / ‫ﻧﻌـﻢ‬ "‫"ﻟﻦ ﺗﺘﻢ ﺍﻟﺘﻐﻄﻴﺔ ﺍﻟﺘﺄﻣﻴﻨﻴﺔ ﻟﻠﺤﺎﻻﺕ ﺃﺩﻧﺎﻩ ﻓﻰ ﺣﺎﻝ ﻋﺪﻡ ﺍﻹﻓﺼﺎﺡ ﻋﻨﻬﺎ‬
Any hospital admission during last 12 months. ‫ ﺷﻬﺮ‬12 ‫ﻫﻞ ﺗﻢ ﺍﻟﺘﻨﻮﻳﻢ ﺑﺎﻟﻤﺴﺘﺸﻔﻰ ﺧﻼﻝ ﺃﺧﺮ‬
"Admission: registering as an admitted patient at the hospital until the following morning "
* * " ‫ ﺗﺴﺠﻴﻞ ﺍﻟﺸﺨﺺ ﺍﻟﻤﺆﻣﻦ ﻟﻪ ﻛﻤﺮﻳﺾ ﻣﻨﻮﻡ ﻓﻲ ﺍﻟﻤﺴﺘﺸﻔﻰ ﺣﺘﻰ ﺻﺒﺎﺡ ﺍﻟﻴﻮﻡ ﺍﻟﺘﺎﻟﻲ‬: ‫" ﺍﻟﺘﻨﻮﻳﻢ‬

Have you been diagnosed with any of the following chronic disease limited ‫ﻫﻞ ﺗﻢ ﺗﺸﺨﻴﺼﻚ ﺑﺄﻯ ﻣﻦ ﺍﻷﻣﺮﺍﺽ ﺍﻟﺘﺎﻟﻴﺔ ﻓﻘﻂ‬
to:Autism, listed Benign Tumor (Breast tumors, fibroid uterus, benign prostatic hyperplasia, ‫ﺃﻭﺭﺍﻡ ﺃﻭ‬,‫ﺗﻀﺨﻢ ﺍﻟﺒﺮﻭﺳﺘﺎﺗﺎ ﺍﻟﺤﻤﻴﺪ‬,‫ ﺃﻭﺭﺍﻡ ﺍﻟﺮﺣﻢ ﺍﻟﻠﻴﻔﻰ‬, ‫ﺍﻻﻭﺭﺍﻡ ﺍﻟﺤﻤﻴﺪﺓ ﺍﻟﺘﺎﻟﻴﺔ )ﺃﻭﺭﺍﻡ ﺍﻟﺜﺪﻯ‬,‫ﺍﻷﻭﺭﺍﻡ ﺍﻟﺴﺮﻃﺎﻧﻴﺔ‬,‫ﺍﻟﺘﻮﺣﺪ‬
thyroid goiter and parathyroid glands, live tumors, colon tumors). Malignant tumors, listed ‫ﺃﻣﺮﺍﺽ ﺍﻟﻘﻠﺐ ﺍﻟﺘﺎﻟﻴﺔ)ﺃﻣﺮﺍﺽ ﺷﺮﺍﻳﻴﻦ ﻭﺻﻤﺎﻣﺎﺕ ﺗﻀﺨﻢ ﺍﻟﻐﺪﺓ ﺍﻟﺪﺭﻗﻴﺔ‬, (‫ﺃﻭﺭﺍﻡ ﺍﻟﻘﻮﻟﻮﻥ‬, ‫ﻭﺃﻭﺭﺍﻡ ﺍﻻﻟﻜﺒﺪ‬,‫ﻭ ﺍﻟﺠﺎﺭ ﺍﻟﺪﺭﻗﻴﺔ‬
Cardiac diseases coronary and valve heart diseases, heart failure, cardiac fibrillation
myocardial infraction, heart clots). Chronic Hepatitis C. Gallstones Sever Kidney failure (stage
* * ‫ﺍﻻﻟﺘﻬﺎﺏ ﺍﻟﻜﺒﺪﻯ ﺍﻟﻔﻴﺮﻭﺳﻰ ﺍﻟﻤﺰﻣﻦ‬.( ‫ﺍﻟﺮﺟﻔﺎﻥ ﺍﻟﻘﻠﺒﻰ ﻭﺟﻠﻄﺎﺕ ﺍﻟﻘﻠﺐ‬, ‫ﻓﺸﻞ ﻋﻀﻠﺔ ﺍﻟﻘﻠﺐ‬, ‫ﺣﺼﻮﺍﺕ ﺍﻟﻤﺮﺍﺭﺓ ﺍﻟﻘﻠﺐ‬, ‫ﺝ ﻭﺳﻰ‬
,‫ ﺍﻟﺘﺮﺷﻴﺢ ﺍﻟﻜﻠﻮﻯ ﺃﻗﻞ ﻣﻦ‬,‫ ﺍﻟﻔﺸﻞ ﺍﻟﻜﻠﻮﻯﺍﻟﺸﺪﻳﺪ )ﺍﻟﻤﺮﺣﻠﺔ ﺍﻟﺨﺎﻣﺴﺔ ﻣﻦ ﺍﻣﺮﺍﺽ ﺍﻟﻜﻠﻰ ﺍﻟﺘﻰ ﺗﺴﺘﺪﻋﻰ ﺍﻟﻐﺴﻴﻞ ﺍﻟﻜﻠﻮﻯ‬15
5 Requiring dialysis, clearance of less tha 15 ml/ minute*). Urinary tract ‫ﻣﺮﺽ‬, ‫ﺩﻗﻴﻘﺔ(ﺣﺼﻮﺍﺕ ﺍﻟﻤﺴﺎﻟﻚ ﺍﻟﺒﻮﻟﻴﺔﺃﻣﺮﺍﺽ ﺍﻟﻤﻨﺎﻋﺔ ﺍﻟﺘﺎﻟﻴﺔ )ﺍﻟﺬﺋﺒﺔ ﺍﻟﺤﻤﺮﺍﺀﻭﺍﻟﺘﻬﺎﺏ ﺍﻟﻤﻔﺎﺻﻞ ﺍﻟﺮﻭﻣﺎﺗﻴﺰﻣﻴﺔﻭ ﺍﻟﺼﺪﻓﻴﺔ‬/‫ﻣﻞ‬
stones, hernias. Autoimmune disease (lupus, rheumatoid arthritis, psoriasis, Crohn's disease, ‫ﺍﻟﺘﻬﺎﺏ ﺍﻟﻘﻮﻟﻮﻥ ﺍﻟﺘﻘﺮﺣﻰ‬, ‫ﻛﺮﻭﻧﺰ‬,
ulcerative colitis,multiple sclerosis, celiac disease) ‫ﺣﺴﺎﺳﻴﺔ ﺍﻟﻘﻤﺢ‬, ‫ﺍﻟﺘﺼﻠﺐ ﺍﻟﻠﻮﻳﺤﻰ‬

Have you been diagnosed with any of the following congenital disorder or
hereditary diseases limited to: Cerebral palsy, Sickle cell disorder, Thalassemia, ‫ﻫﻞ ﺗﻢ ﺗﺸﺨﻴﺼﻚ ﺑﺄﻱ ﻣﻦ ﺍﻷﻣﺮﺍﺽ ﺍﻟﻮﺭﺍﺛﻴﺔ ﺃﻭ ﺍﻟﺘﺸﻮﻫﺎﺕ ﺍﻟﺨﻠﻘﻴﺔ ﺍﻟﺘﺎﻟﻴﺔ ﻓﻘﻂ‬
hemophilia, metabolic diseases, Hydrocephalus, spinal muscle atrophy, genital ‫ ﺿﻤﻮﺭ‬،‫ ﺃﺳﺘﺴﻘﺎﺀ ﺍﻟﺮﺃﺱ‬،‫ ﺃﻣﺮﺍﺽ ﺍﻟﺘﻤﺜﻴﻞ ﺍﻟﻐﺬﺍﺋﻲ‬،‫ ﺍﻟﻬﻴﻤﻮﻓﻴﻠﻴﺎ‬،‫ ﺍﻟﺘﻼﺳﻴﻤﻴﺎ‬،‫ﺍﺿﻄﺮﺍﺏ ﺍﻟﺨﻼﻳﺎ ﺍﻟﻤﻨﺠﻠﻴﺔ‬, ‫ﺍﻟﺸﻠﻞ ﺍﻟﺪﻣﺎﻏﻰ‬
malformations, chromosomal abnormalities. Gaucher's disease, G6PD Deficiency, cystic
fibrosis, hemochromatosis, Wilson disease. Polycystic Kidney Disease.
* * ‫ ﻣﺮﺽ ﺍﻟﺘﻜﺴﺮﺍﻟﻔﻮﻟﻰ‬،‫ ﻣﺮﺽ ﻏﻮﺷﺮ‬،‫ ﺃﻣﺮﺍﺽ ﺍﻟﻜﺮﻭﻣﻮﺳﻮﻣﺎﺕ‬،‫ ﺗﺸﻮﻫﺎﺕ ﺍﻷﻋﻀﺎﺀ ﺍﻟﺘﻨﺎﺳﻠﻴﺔ‬،‫ﺍﻟﻌﻀﻼﺕ ﺍﻟﺸﻮﻛﻲ‬
‫ﺗﻜﻴﺲ‬,‫ﻣﺮﺽ ﻭﻳﻠﺴﻮﻥ‬, (‫ ﻣﺮﺽ ﺗﻜﺪﺱ ﺍﻟﺤﺪﻳﺪ )ﻫﻴﻤﻮﻛﺮﻭﻣﺎﺗﻮﺳﻴﺲ‬،‫( ﺍﻟﺘﻠﻴﻒ ﺍﻟﻜﻴﺴﻲ ﻟﻠﺮﺋﺔ‬G6PD)
‫ﺍﻟﻜﻠﻴﺘﻴﻦ ﺍﻟﺨﻠﻔﻰ ﺍﻟﻮﺭﺍﺋﻰ‬

Have you been diagnosed with any of following eye diseases limited to: ،‫ ﻣﻴﺎﺓ ﺯﺭﻗﺎﺀ‬،‫ ﻣﻴﺎﺓ ﺑﻴﻀﺎﺀ‬:‫ﻫﻞ ﺗﻢ ﺗﺸﺨﻴﺼﻚ ﺑﺄﻱ ﻣﻦ ﺃﻣﺮﺍﺽ ﺍﻟﻌﻴﻦ ﺍﻟﺘﺎﻟﻴﺔ ﻓﻘﻂ‬
Cataract, Glaucoma, Retinal diseases. * * ‫ﺃﻣﺮﺍﺽ ﺍﻟﺸﺒﻜﻴﺔ‬
Have you been diagnosed with any of the following bone diseases limited ‫ ﺍﻹﻧﺰﻻﻕ ﺍﻟﻐﻀﺮﻭﻓﻲ‬:‫ﻫﻞ ﺗﻢ ﺗﺸﺨﻴﺼﻚ ﺑﺄﻱ ﻣﻦ ﺃﻣﺮﺍﺽ ﺍﻟﻌﻈﺎﻡ ﺍﻟﺘﺎﻟﻴﺔ ﻓﻘﻂ‬
to:Vertebral disc prolapse (moderate or severe), Scoliosis (moderate or severe)**, or ligament
tears, osteoarthritis (moderate or severe )
* * ‫ﺗﻤﺰﻕ ﺍﻷﺭﺑﻄﺔ‬،‫ﺍﻟﺘﻬﺎﺏ ﺍﻟﻤﻔﺎﺻﻞ‬،‫ﺇﻧﺤﺮﺍﻑ ﺍﻟﻌﻤﻮﺩ ﺍﻟﻔﻘﺮﻱ‬,‫ﺍﻟﺪﻳﺴﻚ‬

Pregnant Female Only ‫ﻟﻸﻧﺜﻰ ﺍﻟﺤﺎﻣﻞ ﻓﻘﻂ‬

‫ﺣﻤﻞ ﺣﺎﻟﻲ ﺟﻨﻴﻦ ﻭﺍﺣﺪ‬
Current Single Pregnancy
* *
‫ﺣﻤﻞ ﺣﺎﻟﻲ ﻣﻊ ﻗﻴﺼﺮﻳﺔ ﺳﺎﺑﻘﺔ‬
Current Single Pregnancy with Previous CS Delivery
* *
‫ﺣﻤﻞ ﺣﺎﻟﻲ ﻣﺘﻌﺪﺩ ﺍﻷﺟﻨﺔ‬
Current Multiple Pregnancy
* *
Expected delivery date .. / .. / .... ‫ﺗﺎﺭﻳﺦ ﺍﻟﻮﻻﺩﺓ ﺍﻟﻤﺘﻮﻗﻊ‬
Employee and dependents details that need to be added ‫ﺑﻴﺎﻧﺎﺕ ﺍﻟﻤﻮﻇﻒ ﻭﺃﻓﺮﺍﺩ ﺍﻟﻌﺎﺋﻠﺔ ﺍﻟﻤﺮﺍﺩ ﺇﺿﺎﻓﺘﻬﻢ‬
In case of a yes answer above, please declare the case in the table below ‫ ﺍﻟﺮﺟﺎﺀ ﺫﻛﺮ ﺍﻟﺤﺎﻟﺔ ﻓﻲ ﺍﻟﺠﺪﻭﻝ ﺃﺩﻧﺎﻩ‬،‫ﻓﻲ ﺣﺎﻟﺔ ﺍﻹﺟﺎﺑﺔ ﺑﻨﻌﻢ ﺃﻋﻼﻩ‬
‫ﺇﺳﻢ ﻣﻘﺪﻡ ﺍﻟﺨﺪﻣﺔ‬ ‫ﺍﻟﺤﺎﻟﺔ‬ ‫ﺭﻗﻢ ﺍﻟﺠﻮﺍﻝ‬ ‫ﺍﻟﻄﻮﻝ‬ ‫ﺍﻟﻮﺯﻥ‬ ‫ﺭﻗﻢ ﺍﻟﻬﻮﻳﺔ‬ ‫ﺍﻟﻘﺮﺍﺑﺔ‬ ‫ﺍﻟﺠﻨﺲ‬ ‫ ﺃﻓﺮﺍﺩ ﺍﻟﻌﺎﺋﻠﺔ‬/ ‫ﺍﺳﻢ ﺍﻟﻤﻮﻇﻒ‬ ‫ﻡ‬
2358331250 Spouse Female / ‫ ﺃﻧﺜﻰ‬Ayesha Sharif Ahmed Khan 1
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Undertakings : ‫ﺍﻹﻗﺮﺍﺭ ﻭﺍﻟﺘﻔﻮﻳﺾ‬
1- I hereby undertake that all the above information is correct and the acceptance of my ‫ﻭﺍﻟﻤﻌﻠﻮﻣﺎﺕ ﺍﻟﻤﺬﻛﻮﺭﺓ ﺃﻋﻼﻩ ﻛﺎﻣﻠﺔ ﻭﺻﺤﻴﺤﺔ ﻭﺑﻨﺎﺀ ﻋﻠﻴﻪ ﻓﺈﻥ ﻗﺒﻮﻝ ﺍﻟﻄﻠﺐ ﺳﻴﺘﻢ‬: ‫ ﺃﻗﺮ ﺃﻥ ﺍﻟﺒﻴﺎﻧﺎﺕ‬-1
enrollment will be on the basis of such information and that Malath Cooperative Insurance ‫ﻋﻠﻰ ﺃﺳﺎﺱ ﻫﺬﻩ ﺍﻟﺒﻴﺎﻧﺎﺕ ﻭﺃﻥ ﺷﺮﻛﺔ ﻣﻼﺫ ﻟﻠﺘﺄﻣﻴﻦ ﺍﻟﺘﻌﺎﻭﻧﻲ ﻟﻬﺎ ﺍﻟﺤﻖ ﻓﻲ ﺍﻻﺗﺼﺎﻝ ﺑﺎﻟﻤﺴﺘﺸﻔﻴﺎﺕ ﺍﻟﺘﻲ‬
Company has the right to contact the hospital(s) I deal with to collect any ‫ﺃﺗﻌﺎﻣﻞ ﻣﻌﻬﺎ ﻟﺘﺰﻭﻳﺪﻫﺎ ﺑﺄﻱ ﻣﻌﻠﻮﻣﺎﺕ ﻃﺒﻴﺔ ﻗﺪ ﺗﺤﺘﺎﺝ ﺇﻟﻴﻬﺎ ﻟﺘﻘﻴﻴﻢ ﺍﻟﻤﺨﺎﻃﺮ‬
medical information needed to assess the risk(s).

2- I agree that Malath Cooperative Insurance Company has the right to reject the ‫ ﺃﻭﺍﻓﻖ ﻋﻠﻰ ﺃﺣﻘﻴﺔ ﺷﺮﻛﺔ ﻣﻼﺫ ﻟﻠﺘﺄﻣﻴﻦ ﻓﻲ ﺭﻓﺾ ﺍﻟﻤﻄﺎﻟﺒﺔ ﺃﻭ ﺍﻟﺘﻐﻄﻴﺔ ﻛﻠﻴﺎ ﻋﻨﺪ ﻋﺪﻡ ﺍﻹﻓﺼﺎﺡ ﻋﻦ ﻭﺟﻮﺩ ﺃﻱ ﻣﻦ ﺍﻟﺤﺎﻻﺕ‬-2
coverage/claims in full in case of no declaration of any cases prior to the contractual date or ‫ﺍﻟﻤﺬﻛﻮﺭﺓ ﺃﻋﻼﻩ ﺍﻟﺘﻲ ﻧﺸﺄﺕ ﻗﺒﻞ ﺗﺎﺭﻳﺦ ﺍﻟﺘﻌﺎﻗﺪ ﺃﻭ ﻗﺒﻞ ﺗﺴﺠﻴﻞ ﺃﻭ ﺇﺿﺎﻓﺔ ﻋﻀﻮ ﺧﻼﻝ ﻓﺘﺮﺓ ﺳﺮﻳﺎﻥ ﺍﻟﻌﻘﺪ‬
before enrolling or adding a new member during the contract.

3- I hereby confirm reading and understanding all points presented in this form and I agree that ‫ ﺃﻗﺮﺑﺄﻧﻲ ﻗﺪ ﻗﺮﺃﺕ ﻭﻓﻬﻤﺖ ﺟﻤﻴﻊ ﻣﺎ ﺟﺎﺀ ﻓﻲ ﻫﺬﺍ ﺍﻟﻨﻤﻮﺫﺝ ﻛﻤﺎ ﺃﺗﻌﻬﺪ ﺑﺄﻥ ﻋﺪﻡ ﺇﺷﺎﺭﺗﻲ ﺃﻣﺎﻡ ﺃﻱ ﻣﻦ‬-3
not marking any case is understood as “Nothing requires declaration” and I sign on these ‫ﺍﻟﺤﺎﻻﺕ ﺍﻟﻤﺬﻛﻮﺭﺓ ﺃﻋﻼﻩ ﻳﻌﺘﺒﺮ ﺑﻤﺜﺎﺑﺔ ﻧﻔﻲ ﻭﺟﻮﺩ ﻣﺎﻳﺴﺘﺤﻖ ﺍﻹﻓﺼﺎﺡ ﻋﻨﻪ ﻭﻋﻠﻴﻪ ﺃﻭﻗﻊ‬
basis.
4- Failure to fill the weight and height information will result in refusal to cover
the cost of obesity surgery. ‫ ﻋﺪﻡ ﺗﻌﺒﺌﺔ ﺑﻴﺎﻧﺎﺕ ﺍﻟﻄﻮﻝ ﻭﺍﻟﻮﺯﻥ ﺳﻴﺆﺩﻱ ﺇﻟﻰ ﺭﻓﺾ ﺗﻐﻄﻴﺔ ﺗﻜﺎﻟﻴﻒ ﻋﻤﻠﻴﺔ ﺟﺮﺍﺣﺔ ﺍﻟﺴﻤﻨﺔ ﺍﻟﻤﻔﺮﻃﺔ‬-4

Entity's stamp ‫ﺧﺘﻢ ﺟﻬﺔ ﺍﻟﻌﻤﻞ‬ Insured Signature ‫ﺗﻮﻗﻴﻊ ﺍﻟﻤﻮﻇﻒ‬ Date ‫ﺍﻟﺘﺎﺭﻳﺦ‬
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New_Health_Insurance.rdf Page 17 of 39 V.20 13-DEC-2023 01:30 PM

 ‫ﻧﻤﻮﺫﺝ ﺍﻻﻓﺼﺎﺡ ﺍﻟﻄﺒﻲ ﺍﻟﻤﻮﺣﺪ‬
Unified Medical Declaration Form
Product Code: A-MLTH-2-C-08-014
Dear Insured: ‫ﻋﺰﻳﺰﻱ ﺍﻟﻤﺆﻣﻦ ﻟﻪ‬
Please Fill out the form correctly for the purpose of pricing and to ensured that you and your ‫ﻧﺄﻣﻞ ﻗﻴﺎﻣﻚ ﺑﺘﻌﺒﺌﺔ ﻫﺬﺍ ﺍﻟﻨﻤﻮﺫﺝ ﺑﺎﻟﺸﻜﻞ ﺍﻟﺼﺤﻴﺢ ﻟﻐﺮﺽ ﺍﻟﺘﺴﻌﻴﺮ ﻭﻟﻀﻤﺎﻥ ﺣﺼﻮﻟﻚ ﻭﺃﻓﺮﺍﺩ ﺃﺳﺮﺗﻚ ﻋﻠﻰ ﺧﺪﻣﺎﺕ‬
family receive health care services as required according to your unfied policy benefit ‫ﺍﻟﺮﻋﺎﻳﺔ ﺍﻟﺼﺤﻴﺔ ﺑﺎﻟﺸﻜﻞ ﺍﻟﻤﻄﻠﻮﺏ ﺣﺴﺐ ﻣﻨﺎﻓﻊ ﺍﻟﻮﺛﻴﻘﺔ ﺍﻟﻤﻮﺣﺪﺓ‬

Addition ‫ﺇﺿﺎﻓﺔ‬ New ‫ﺟﺪﻳﺪ‬ Type ‫ﻧﻮﻉ ﺍﻟﻄﻠﺐ‬

CR No 7011507360 ‫ﺍﻟﺴﺠﻞ ﺍﻟﺘﺠﺎﺭﻱ‬ Entity Name HADDAJ AL HIJAZ EST ‫ﺃﺳﻢ ﺍﻟﻤﻨﺸﺄﺓ‬
Mobile No 0553220574 ‫ﺭﻗﻢ ﺍﻟﺠﻮﺍﻝ‬ Areej Ahmed Siddiqui ‫ﺍﺳﻢ ﺍﻟﻤﻮﻇﻒ‬
ID Number 2 3 5 8 3 3 1 2 6 8 ‫ﺭﻗﻢ ﺍﻟﻬﻮﻳﺔ‬
Gender Female / ‫ﺍﻟﺠﻨﺲ ﺃﻧﺜﻰ‬ Nationality India ‫ ﺍﻟﺠﻨﺴﻴﺔ‬Marital status Married * ‫ﻣﺘﺰﻭﺝ‬ Single R ‫ﺃﻋﺰﺏ‬ ‫ﺍﻟﺤﺎﻟﺔ ﺍﻻﺟﺘﻤﺎﻋﻴﺔ‬
Please declare any of the below cases by marking P under the word Yes ‫ ﻓﻲ ﺍﻟﻤﺮﺑﻊ ﺗﺤﺖ ﻛﻠﻤﺔ ﻧﻌﻢ‬P ‫ﻳﺮﺟﻰ ﺍﻹﻓﺼﺎﺡ ﻋﻦ ﻭﺟﻮﺩ ﺃﻱ ﻣﻦ ﺍﻟﺤﺎﻻﺕ ﺍﺩﻧﺎﻩ ﺑﻮﺿﻊ ﺇﺷﺎﺭﺓ‬
"Below Undeclared Medical Case May Not Be Covered" No / ‫ﻻ‬ Yes / ‫ﻧﻌـﻢ‬ "‫"ﻟﻦ ﺗﺘﻢ ﺍﻟﺘﻐﻄﻴﺔ ﺍﻟﺘﺄﻣﻴﻨﻴﺔ ﻟﻠﺤﺎﻻﺕ ﺃﺩﻧﺎﻩ ﻓﻰ ﺣﺎﻝ ﻋﺪﻡ ﺍﻹﻓﺼﺎﺡ ﻋﻨﻬﺎ‬
Any hospital admission during last 12 months. ‫ ﺷﻬﺮ‬12 ‫ﻫﻞ ﺗﻢ ﺍﻟﺘﻨﻮﻳﻢ ﺑﺎﻟﻤﺴﺘﺸﻔﻰ ﺧﻼﻝ ﺃﺧﺮ‬
"Admission: registering as an admitted patient at the hospital until the following morning "
* * " ‫ ﺗﺴﺠﻴﻞ ﺍﻟﺸﺨﺺ ﺍﻟﻤﺆﻣﻦ ﻟﻪ ﻛﻤﺮﻳﺾ ﻣﻨﻮﻡ ﻓﻲ ﺍﻟﻤﺴﺘﺸﻔﻰ ﺣﺘﻰ ﺻﺒﺎﺡ ﺍﻟﻴﻮﻡ ﺍﻟﺘﺎﻟﻲ‬: ‫" ﺍﻟﺘﻨﻮﻳﻢ‬

Have you been diagnosed with any of the following chronic disease limited ‫ﻫﻞ ﺗﻢ ﺗﺸﺨﻴﺼﻚ ﺑﺄﻯ ﻣﻦ ﺍﻷﻣﺮﺍﺽ ﺍﻟﺘﺎﻟﻴﺔ ﻓﻘﻂ‬
to:Autism, listed Benign Tumor (Breast tumors, fibroid uterus, benign prostatic hyperplasia, ‫ﺃﻭﺭﺍﻡ ﺃﻭ‬,‫ﺗﻀﺨﻢ ﺍﻟﺒﺮﻭﺳﺘﺎﺗﺎ ﺍﻟﺤﻤﻴﺪ‬,‫ ﺃﻭﺭﺍﻡ ﺍﻟﺮﺣﻢ ﺍﻟﻠﻴﻔﻰ‬, ‫ﺍﻻﻭﺭﺍﻡ ﺍﻟﺤﻤﻴﺪﺓ ﺍﻟﺘﺎﻟﻴﺔ )ﺃﻭﺭﺍﻡ ﺍﻟﺜﺪﻯ‬,‫ﺍﻷﻭﺭﺍﻡ ﺍﻟﺴﺮﻃﺎﻧﻴﺔ‬,‫ﺍﻟﺘﻮﺣﺪ‬
thyroid goiter and parathyroid glands, live tumors, colon tumors). Malignant tumors, listed ‫ﺃﻣﺮﺍﺽ ﺍﻟﻘﻠﺐ ﺍﻟﺘﺎﻟﻴﺔ)ﺃﻣﺮﺍﺽ ﺷﺮﺍﻳﻴﻦ ﻭﺻﻤﺎﻣﺎﺕ ﺗﻀﺨﻢ ﺍﻟﻐﺪﺓ ﺍﻟﺪﺭﻗﻴﺔ‬, (‫ﺃﻭﺭﺍﻡ ﺍﻟﻘﻮﻟﻮﻥ‬, ‫ﻭﺃﻭﺭﺍﻡ ﺍﻻﻟﻜﺒﺪ‬,‫ﻭ ﺍﻟﺠﺎﺭ ﺍﻟﺪﺭﻗﻴﺔ‬
Cardiac diseases coronary and valve heart diseases, heart failure, cardiac fibrillation
myocardial infraction, heart clots). Chronic Hepatitis C. Gallstones Sever Kidney failure (stage
* * ‫ﺍﻻﻟﺘﻬﺎﺏ ﺍﻟﻜﺒﺪﻯ ﺍﻟﻔﻴﺮﻭﺳﻰ ﺍﻟﻤﺰﻣﻦ‬.( ‫ﺍﻟﺮﺟﻔﺎﻥ ﺍﻟﻘﻠﺒﻰ ﻭﺟﻠﻄﺎﺕ ﺍﻟﻘﻠﺐ‬, ‫ﻓﺸﻞ ﻋﻀﻠﺔ ﺍﻟﻘﻠﺐ‬, ‫ﺣﺼﻮﺍﺕ ﺍﻟﻤﺮﺍﺭﺓ ﺍﻟﻘﻠﺐ‬, ‫ﺝ ﻭﺳﻰ‬
,‫ ﺍﻟﺘﺮﺷﻴﺢ ﺍﻟﻜﻠﻮﻯ ﺃﻗﻞ ﻣﻦ‬,‫ ﺍﻟﻔﺸﻞ ﺍﻟﻜﻠﻮﻯﺍﻟﺸﺪﻳﺪ )ﺍﻟﻤﺮﺣﻠﺔ ﺍﻟﺨﺎﻣﺴﺔ ﻣﻦ ﺍﻣﺮﺍﺽ ﺍﻟﻜﻠﻰ ﺍﻟﺘﻰ ﺗﺴﺘﺪﻋﻰ ﺍﻟﻐﺴﻴﻞ ﺍﻟﻜﻠﻮﻯ‬15
5 Requiring dialysis, clearance of less tha 15 ml/ minute*). Urinary tract ‫ﻣﺮﺽ‬, ‫ﺩﻗﻴﻘﺔ(ﺣﺼﻮﺍﺕ ﺍﻟﻤﺴﺎﻟﻚ ﺍﻟﺒﻮﻟﻴﺔﺃﻣﺮﺍﺽ ﺍﻟﻤﻨﺎﻋﺔ ﺍﻟﺘﺎﻟﻴﺔ )ﺍﻟﺬﺋﺒﺔ ﺍﻟﺤﻤﺮﺍﺀﻭﺍﻟﺘﻬﺎﺏ ﺍﻟﻤﻔﺎﺻﻞ ﺍﻟﺮﻭﻣﺎﺗﻴﺰﻣﻴﺔﻭ ﺍﻟﺼﺪﻓﻴﺔ‬/‫ﻣﻞ‬
stones, hernias. Autoimmune disease (lupus, rheumatoid arthritis, psoriasis, Crohn's disease, ‫ﺍﻟﺘﻬﺎﺏ ﺍﻟﻘﻮﻟﻮﻥ ﺍﻟﺘﻘﺮﺣﻰ‬, ‫ﻛﺮﻭﻧﺰ‬,
ulcerative colitis,multiple sclerosis, celiac disease) ‫ﺣﺴﺎﺳﻴﺔ ﺍﻟﻘﻤﺢ‬, ‫ﺍﻟﺘﺼﻠﺐ ﺍﻟﻠﻮﻳﺤﻰ‬

Have you been diagnosed with any of the following congenital disorder or
hereditary diseases limited to: Cerebral palsy, Sickle cell disorder, Thalassemia, ‫ﻫﻞ ﺗﻢ ﺗﺸﺨﻴﺼﻚ ﺑﺄﻱ ﻣﻦ ﺍﻷﻣﺮﺍﺽ ﺍﻟﻮﺭﺍﺛﻴﺔ ﺃﻭ ﺍﻟﺘﺸﻮﻫﺎﺕ ﺍﻟﺨﻠﻘﻴﺔ ﺍﻟﺘﺎﻟﻴﺔ ﻓﻘﻂ‬
hemophilia, metabolic diseases, Hydrocephalus, spinal muscle atrophy, genital ‫ ﺿﻤﻮﺭ‬،‫ ﺃﺳﺘﺴﻘﺎﺀ ﺍﻟﺮﺃﺱ‬،‫ ﺃﻣﺮﺍﺽ ﺍﻟﺘﻤﺜﻴﻞ ﺍﻟﻐﺬﺍﺋﻲ‬،‫ ﺍﻟﻬﻴﻤﻮﻓﻴﻠﻴﺎ‬،‫ ﺍﻟﺘﻼﺳﻴﻤﻴﺎ‬،‫ﺍﺿﻄﺮﺍﺏ ﺍﻟﺨﻼﻳﺎ ﺍﻟﻤﻨﺠﻠﻴﺔ‬, ‫ﺍﻟﺸﻠﻞ ﺍﻟﺪﻣﺎﻏﻰ‬
malformations, chromosomal abnormalities. Gaucher's disease, G6PD Deficiency, cystic
fibrosis, hemochromatosis, Wilson disease. Polycystic Kidney Disease.
* * ‫ ﻣﺮﺽ ﺍﻟﺘﻜﺴﺮﺍﻟﻔﻮﻟﻰ‬،‫ ﻣﺮﺽ ﻏﻮﺷﺮ‬،‫ ﺃﻣﺮﺍﺽ ﺍﻟﻜﺮﻭﻣﻮﺳﻮﻣﺎﺕ‬،‫ ﺗﺸﻮﻫﺎﺕ ﺍﻷﻋﻀﺎﺀ ﺍﻟﺘﻨﺎﺳﻠﻴﺔ‬،‫ﺍﻟﻌﻀﻼﺕ ﺍﻟﺸﻮﻛﻲ‬
‫ﺗﻜﻴﺲ‬,‫ﻣﺮﺽ ﻭﻳﻠﺴﻮﻥ‬, (‫ ﻣﺮﺽ ﺗﻜﺪﺱ ﺍﻟﺤﺪﻳﺪ )ﻫﻴﻤﻮﻛﺮﻭﻣﺎﺗﻮﺳﻴﺲ‬،‫( ﺍﻟﺘﻠﻴﻒ ﺍﻟﻜﻴﺴﻲ ﻟﻠﺮﺋﺔ‬G6PD)
‫ﺍﻟﻜﻠﻴﺘﻴﻦ ﺍﻟﺨﻠﻔﻰ ﺍﻟﻮﺭﺍﺋﻰ‬

Have you been diagnosed with any of following eye diseases limited to: ،‫ ﻣﻴﺎﺓ ﺯﺭﻗﺎﺀ‬،‫ ﻣﻴﺎﺓ ﺑﻴﻀﺎﺀ‬:‫ﻫﻞ ﺗﻢ ﺗﺸﺨﻴﺼﻚ ﺑﺄﻱ ﻣﻦ ﺃﻣﺮﺍﺽ ﺍﻟﻌﻴﻦ ﺍﻟﺘﺎﻟﻴﺔ ﻓﻘﻂ‬
Cataract, Glaucoma, Retinal diseases. * * ‫ﺃﻣﺮﺍﺽ ﺍﻟﺸﺒﻜﻴﺔ‬
Have you been diagnosed with any of the following bone diseases limited ‫ ﺍﻹﻧﺰﻻﻕ ﺍﻟﻐﻀﺮﻭﻓﻲ‬:‫ﻫﻞ ﺗﻢ ﺗﺸﺨﻴﺼﻚ ﺑﺄﻱ ﻣﻦ ﺃﻣﺮﺍﺽ ﺍﻟﻌﻈﺎﻡ ﺍﻟﺘﺎﻟﻴﺔ ﻓﻘﻂ‬
to:Vertebral disc prolapse (moderate or severe), Scoliosis (moderate or severe)**, or ligament
tears, osteoarthritis (moderate or severe )
* * ‫ﺗﻤﺰﻕ ﺍﻷﺭﺑﻄﺔ‬،‫ﺍﻟﺘﻬﺎﺏ ﺍﻟﻤﻔﺎﺻﻞ‬،‫ﺇﻧﺤﺮﺍﻑ ﺍﻟﻌﻤﻮﺩ ﺍﻟﻔﻘﺮﻱ‬,‫ﺍﻟﺪﻳﺴﻚ‬

Pregnant Female Only ‫ﻟﻸﻧﺜﻰ ﺍﻟﺤﺎﻣﻞ ﻓﻘﻂ‬

‫ﺣﻤﻞ ﺣﺎﻟﻲ ﺟﻨﻴﻦ ﻭﺍﺣﺪ‬
Current Single Pregnancy
* *
‫ﺣﻤﻞ ﺣﺎﻟﻲ ﻣﻊ ﻗﻴﺼﺮﻳﺔ ﺳﺎﺑﻘﺔ‬
Current Single Pregnancy with Previous CS Delivery
* *
‫ﺣﻤﻞ ﺣﺎﻟﻲ ﻣﺘﻌﺪﺩ ﺍﻷﺟﻨﺔ‬
Current Multiple Pregnancy
* *
Expected delivery date .. / .. / .... ‫ﺗﺎﺭﻳﺦ ﺍﻟﻮﻻﺩﺓ ﺍﻟﻤﺘﻮﻗﻊ‬
Employee and dependents details that need to be added ‫ﺑﻴﺎﻧﺎﺕ ﺍﻟﻤﻮﻇﻒ ﻭﺃﻓﺮﺍﺩ ﺍﻟﻌﺎﺋﻠﺔ ﺍﻟﻤﺮﺍﺩ ﺇﺿﺎﻓﺘﻬﻢ‬
In case of a yes answer above, please declare the case in the table below ‫ ﺍﻟﺮﺟﺎﺀ ﺫﻛﺮ ﺍﻟﺤﺎﻟﺔ ﻓﻲ ﺍﻟﺠﺪﻭﻝ ﺃﺩﻧﺎﻩ‬،‫ﻓﻲ ﺣﺎﻟﺔ ﺍﻹﺟﺎﺑﺔ ﺑﻨﻌﻢ ﺃﻋﻼﻩ‬
‫ﺇﺳﻢ ﻣﻘﺪﻡ ﺍﻟﺨﺪﻣﺔ‬ ‫ﺍﻟﺤﺎﻟﺔ‬ ‫ﺭﻗﻢ ﺍﻟﺠﻮﺍﻝ‬ ‫ﺍﻟﻄﻮﻝ‬ ‫ﺍﻟﻮﺯﻥ‬ ‫ﺭﻗﻢ ﺍﻟﻬﻮﻳﺔ‬ ‫ﺍﻟﻘﺮﺍﺑﺔ‬ ‫ﺍﻟﺠﻨﺲ‬ ‫ ﺃﻓﺮﺍﺩ ﺍﻟﻌﺎﺋﻠﺔ‬/ ‫ﺍﺳﻢ ﺍﻟﻤﻮﻇﻒ‬ ‫ﻡ‬
2358331268 Child Female / ‫ ﺃﻧﺜﻰ‬Areej Ahmed Siddiqui 1
2
3
4
5
Undertakings : ‫ﺍﻹﻗﺮﺍﺭ ﻭﺍﻟﺘﻔﻮﻳﺾ‬
1- I hereby undertake that all the above information is correct and the acceptance of my ‫ﻭﺍﻟﻤﻌﻠﻮﻣﺎﺕ ﺍﻟﻤﺬﻛﻮﺭﺓ ﺃﻋﻼﻩ ﻛﺎﻣﻠﺔ ﻭﺻﺤﻴﺤﺔ ﻭﺑﻨﺎﺀ ﻋﻠﻴﻪ ﻓﺈﻥ ﻗﺒﻮﻝ ﺍﻟﻄﻠﺐ ﺳﻴﺘﻢ‬: ‫ ﺃﻗﺮ ﺃﻥ ﺍﻟﺒﻴﺎﻧﺎﺕ‬-1
enrollment will be on the basis of such information and that Malath Cooperative Insurance ‫ﻋﻠﻰ ﺃﺳﺎﺱ ﻫﺬﻩ ﺍﻟﺒﻴﺎﻧﺎﺕ ﻭﺃﻥ ﺷﺮﻛﺔ ﻣﻼﺫ ﻟﻠﺘﺄﻣﻴﻦ ﺍﻟﺘﻌﺎﻭﻧﻲ ﻟﻬﺎ ﺍﻟﺤﻖ ﻓﻲ ﺍﻻﺗﺼﺎﻝ ﺑﺎﻟﻤﺴﺘﺸﻔﻴﺎﺕ ﺍﻟﺘﻲ‬
Company has the right to contact the hospital(s) I deal with to collect any ‫ﺃﺗﻌﺎﻣﻞ ﻣﻌﻬﺎ ﻟﺘﺰﻭﻳﺪﻫﺎ ﺑﺄﻱ ﻣﻌﻠﻮﻣﺎﺕ ﻃﺒﻴﺔ ﻗﺪ ﺗﺤﺘﺎﺝ ﺇﻟﻴﻬﺎ ﻟﺘﻘﻴﻴﻢ ﺍﻟﻤﺨﺎﻃﺮ‬
medical information needed to assess the risk(s).

2- I agree that Malath Cooperative Insurance Company has the right to reject the ‫ ﺃﻭﺍﻓﻖ ﻋﻠﻰ ﺃﺣﻘﻴﺔ ﺷﺮﻛﺔ ﻣﻼﺫ ﻟﻠﺘﺄﻣﻴﻦ ﻓﻲ ﺭﻓﺾ ﺍﻟﻤﻄﺎﻟﺒﺔ ﺃﻭ ﺍﻟﺘﻐﻄﻴﺔ ﻛﻠﻴﺎ ﻋﻨﺪ ﻋﺪﻡ ﺍﻹﻓﺼﺎﺡ ﻋﻦ ﻭﺟﻮﺩ ﺃﻱ ﻣﻦ ﺍﻟﺤﺎﻻﺕ‬-2
coverage/claims in full in case of no declaration of any cases prior to the contractual date or ‫ﺍﻟﻤﺬﻛﻮﺭﺓ ﺃﻋﻼﻩ ﺍﻟﺘﻲ ﻧﺸﺄﺕ ﻗﺒﻞ ﺗﺎﺭﻳﺦ ﺍﻟﺘﻌﺎﻗﺪ ﺃﻭ ﻗﺒﻞ ﺗﺴﺠﻴﻞ ﺃﻭ ﺇﺿﺎﻓﺔ ﻋﻀﻮ ﺧﻼﻝ ﻓﺘﺮﺓ ﺳﺮﻳﺎﻥ ﺍﻟﻌﻘﺪ‬
before enrolling or adding a new member during the contract.

3- I hereby confirm reading and understanding all points presented in this form and I agree that ‫ ﺃﻗﺮﺑﺄﻧﻲ ﻗﺪ ﻗﺮﺃﺕ ﻭﻓﻬﻤﺖ ﺟﻤﻴﻊ ﻣﺎ ﺟﺎﺀ ﻓﻲ ﻫﺬﺍ ﺍﻟﻨﻤﻮﺫﺝ ﻛﻤﺎ ﺃﺗﻌﻬﺪ ﺑﺄﻥ ﻋﺪﻡ ﺇﺷﺎﺭﺗﻲ ﺃﻣﺎﻡ ﺃﻱ ﻣﻦ‬-3
not marking any case is understood as “Nothing requires declaration” and I sign on these ‫ﺍﻟﺤﺎﻻﺕ ﺍﻟﻤﺬﻛﻮﺭﺓ ﺃﻋﻼﻩ ﻳﻌﺘﺒﺮ ﺑﻤﺜﺎﺑﺔ ﻧﻔﻲ ﻭﺟﻮﺩ ﻣﺎﻳﺴﺘﺤﻖ ﺍﻹﻓﺼﺎﺡ ﻋﻨﻪ ﻭﻋﻠﻴﻪ ﺃﻭﻗﻊ‬
basis.
4- Failure to fill the weight and height information will result in refusal to cover
the cost of obesity surgery. ‫ ﻋﺪﻡ ﺗﻌﺒﺌﺔ ﺑﻴﺎﻧﺎﺕ ﺍﻟﻄﻮﻝ ﻭﺍﻟﻮﺯﻥ ﺳﻴﺆﺩﻱ ﺇﻟﻰ ﺭﻓﺾ ﺗﻐﻄﻴﺔ ﺗﻜﺎﻟﻴﻒ ﻋﻤﻠﻴﺔ ﺟﺮﺍﺣﺔ ﺍﻟﺴﻤﻨﺔ ﺍﻟﻤﻔﺮﻃﺔ‬-4

Entity's stamp ‫ﺧﺘﻢ ﺟﻬﺔ ﺍﻟﻌﻤﻞ‬ Insured Signature ‫ﺗﻮﻗﻴﻊ ﺍﻟﻤﻮﻇﻒ‬ Date ‫ﺍﻟﺘﺎﺭﻳﺦ‬
.. / .. / ....

New_Health_Insurance.rdf Page 18 of 39 V.20 13-DEC-2023 01:30 PM

 ‫ﻧﻤﻮﺫﺝ ﺍﻻﻓﺼﺎﺡ ﺍﻟﻄﺒﻲ ﺍﻟﻤﻮﺣﺪ‬
Unified Medical Declaration Form
Product Code: A-MLTH-2-C-08-014
Dear Insured: ‫ﻋﺰﻳﺰﻱ ﺍﻟﻤﺆﻣﻦ ﻟﻪ‬
Please Fill out the form correctly for the purpose of pricing and to ensured that you and your ‫ﻧﺄﻣﻞ ﻗﻴﺎﻣﻚ ﺑﺘﻌﺒﺌﺔ ﻫﺬﺍ ﺍﻟﻨﻤﻮﺫﺝ ﺑﺎﻟﺸﻜﻞ ﺍﻟﺼﺤﻴﺢ ﻟﻐﺮﺽ ﺍﻟﺘﺴﻌﻴﺮ ﻭﻟﻀﻤﺎﻥ ﺣﺼﻮﻟﻚ ﻭﺃﻓﺮﺍﺩ ﺃﺳﺮﺗﻚ ﻋﻠﻰ ﺧﺪﻣﺎﺕ‬
family receive health care services as required according to your unfied policy benefit ‫ﺍﻟﺮﻋﺎﻳﺔ ﺍﻟﺼﺤﻴﺔ ﺑﺎﻟﺸﻜﻞ ﺍﻟﻤﻄﻠﻮﺏ ﺣﺴﺐ ﻣﻨﺎﻓﻊ ﺍﻟﻮﺛﻴﻘﺔ ﺍﻟﻤﻮﺣﺪﺓ‬

Addition ‫ﺇﺿﺎﻓﺔ‬ New ‫ﺟﺪﻳﺪ‬ Type ‫ﻧﻮﻉ ﺍﻟﻄﻠﺐ‬

CR No 7011507360 ‫ﺍﻟﺴﺠﻞ ﺍﻟﺘﺠﺎﺭﻱ‬ Entity Name HADDAJ AL HIJAZ EST ‫ﺃﺳﻢ ﺍﻟﻤﻨﺸﺄﺓ‬
Mobile No 0553220574 ‫ﺭﻗﻢ ﺍﻟﺠﻮﺍﻝ‬ Arwa Ahmad Khaliqullah ‫ﺍﺳﻢ ﺍﻟﻤﻮﻇﻒ‬
ID Number 2 3 6 6 2 4 9 2 9 6 ‫ﺭﻗﻢ ﺍﻟﻬﻮﻳﺔ‬
Gender Female / ‫ﺍﻟﺠﻨﺲ ﺃﻧﺜﻰ‬ Nationality India ‫ ﺍﻟﺠﻨﺴﻴﺔ‬Marital status Married * ‫ﻣﺘﺰﻭﺝ‬ Single R ‫ﺃﻋﺰﺏ‬ ‫ﺍﻟﺤﺎﻟﺔ ﺍﻻﺟﺘﻤﺎﻋﻴﺔ‬
Please declare any of the below cases by marking P under the word Yes ‫ ﻓﻲ ﺍﻟﻤﺮﺑﻊ ﺗﺤﺖ ﻛﻠﻤﺔ ﻧﻌﻢ‬P ‫ﻳﺮﺟﻰ ﺍﻹﻓﺼﺎﺡ ﻋﻦ ﻭﺟﻮﺩ ﺃﻱ ﻣﻦ ﺍﻟﺤﺎﻻﺕ ﺍﺩﻧﺎﻩ ﺑﻮﺿﻊ ﺇﺷﺎﺭﺓ‬
"Below Undeclared Medical Case May Not Be Covered" No / ‫ﻻ‬ Yes / ‫ﻧﻌـﻢ‬ "‫"ﻟﻦ ﺗﺘﻢ ﺍﻟﺘﻐﻄﻴﺔ ﺍﻟﺘﺄﻣﻴﻨﻴﺔ ﻟﻠﺤﺎﻻﺕ ﺃﺩﻧﺎﻩ ﻓﻰ ﺣﺎﻝ ﻋﺪﻡ ﺍﻹﻓﺼﺎﺡ ﻋﻨﻬﺎ‬
Any hospital admission during last 12 months. ‫ ﺷﻬﺮ‬12 ‫ﻫﻞ ﺗﻢ ﺍﻟﺘﻨﻮﻳﻢ ﺑﺎﻟﻤﺴﺘﺸﻔﻰ ﺧﻼﻝ ﺃﺧﺮ‬
"Admission: registering as an admitted patient at the hospital until the following morning "
* * " ‫ ﺗﺴﺠﻴﻞ ﺍﻟﺸﺨﺺ ﺍﻟﻤﺆﻣﻦ ﻟﻪ ﻛﻤﺮﻳﺾ ﻣﻨﻮﻡ ﻓﻲ ﺍﻟﻤﺴﺘﺸﻔﻰ ﺣﺘﻰ ﺻﺒﺎﺡ ﺍﻟﻴﻮﻡ ﺍﻟﺘﺎﻟﻲ‬: ‫" ﺍﻟﺘﻨﻮﻳﻢ‬

Have you been diagnosed with any of the following chronic disease limited ‫ﻫﻞ ﺗﻢ ﺗﺸﺨﻴﺼﻚ ﺑﺄﻯ ﻣﻦ ﺍﻷﻣﺮﺍﺽ ﺍﻟﺘﺎﻟﻴﺔ ﻓﻘﻂ‬
to:Autism, listed Benign Tumor (Breast tumors, fibroid uterus, benign prostatic hyperplasia, ‫ﺃﻭﺭﺍﻡ ﺃﻭ‬,‫ﺗﻀﺨﻢ ﺍﻟﺒﺮﻭﺳﺘﺎﺗﺎ ﺍﻟﺤﻤﻴﺪ‬,‫ ﺃﻭﺭﺍﻡ ﺍﻟﺮﺣﻢ ﺍﻟﻠﻴﻔﻰ‬, ‫ﺍﻻﻭﺭﺍﻡ ﺍﻟﺤﻤﻴﺪﺓ ﺍﻟﺘﺎﻟﻴﺔ )ﺃﻭﺭﺍﻡ ﺍﻟﺜﺪﻯ‬,‫ﺍﻷﻭﺭﺍﻡ ﺍﻟﺴﺮﻃﺎﻧﻴﺔ‬,‫ﺍﻟﺘﻮﺣﺪ‬
thyroid goiter and parathyroid glands, live tumors, colon tumors). Malignant tumors, listed ‫ﺃﻣﺮﺍﺽ ﺍﻟﻘﻠﺐ ﺍﻟﺘﺎﻟﻴﺔ)ﺃﻣﺮﺍﺽ ﺷﺮﺍﻳﻴﻦ ﻭﺻﻤﺎﻣﺎﺕ ﺗﻀﺨﻢ ﺍﻟﻐﺪﺓ ﺍﻟﺪﺭﻗﻴﺔ‬, (‫ﺃﻭﺭﺍﻡ ﺍﻟﻘﻮﻟﻮﻥ‬, ‫ﻭﺃﻭﺭﺍﻡ ﺍﻻﻟﻜﺒﺪ‬,‫ﻭ ﺍﻟﺠﺎﺭ ﺍﻟﺪﺭﻗﻴﺔ‬
Cardiac diseases coronary and valve heart diseases, heart failure, cardiac fibrillation
myocardial infraction, heart clots). Chronic Hepatitis C. Gallstones Sever Kidney failure (stage
* * ‫ﺍﻻﻟﺘﻬﺎﺏ ﺍﻟﻜﺒﺪﻯ ﺍﻟﻔﻴﺮﻭﺳﻰ ﺍﻟﻤﺰﻣﻦ‬.( ‫ﺍﻟﺮﺟﻔﺎﻥ ﺍﻟﻘﻠﺒﻰ ﻭﺟﻠﻄﺎﺕ ﺍﻟﻘﻠﺐ‬, ‫ﻓﺸﻞ ﻋﻀﻠﺔ ﺍﻟﻘﻠﺐ‬, ‫ﺣﺼﻮﺍﺕ ﺍﻟﻤﺮﺍﺭﺓ ﺍﻟﻘﻠﺐ‬, ‫ﺝ ﻭﺳﻰ‬
,‫ ﺍﻟﺘﺮﺷﻴﺢ ﺍﻟﻜﻠﻮﻯ ﺃﻗﻞ ﻣﻦ‬,‫ ﺍﻟﻔﺸﻞ ﺍﻟﻜﻠﻮﻯﺍﻟﺸﺪﻳﺪ )ﺍﻟﻤﺮﺣﻠﺔ ﺍﻟﺨﺎﻣﺴﺔ ﻣﻦ ﺍﻣﺮﺍﺽ ﺍﻟﻜﻠﻰ ﺍﻟﺘﻰ ﺗﺴﺘﺪﻋﻰ ﺍﻟﻐﺴﻴﻞ ﺍﻟﻜﻠﻮﻯ‬15
5 Requiring dialysis, clearance of less tha 15 ml/ minute*). Urinary tract ‫ﻣﺮﺽ‬, ‫ﺩﻗﻴﻘﺔ(ﺣﺼﻮﺍﺕ ﺍﻟﻤﺴﺎﻟﻚ ﺍﻟﺒﻮﻟﻴﺔﺃﻣﺮﺍﺽ ﺍﻟﻤﻨﺎﻋﺔ ﺍﻟﺘﺎﻟﻴﺔ )ﺍﻟﺬﺋﺒﺔ ﺍﻟﺤﻤﺮﺍﺀﻭﺍﻟﺘﻬﺎﺏ ﺍﻟﻤﻔﺎﺻﻞ ﺍﻟﺮﻭﻣﺎﺗﻴﺰﻣﻴﺔﻭ ﺍﻟﺼﺪﻓﻴﺔ‬/‫ﻣﻞ‬
stones, hernias. Autoimmune disease (lupus, rheumatoid arthritis, psoriasis, Crohn's disease, ‫ﺍﻟﺘﻬﺎﺏ ﺍﻟﻘﻮﻟﻮﻥ ﺍﻟﺘﻘﺮﺣﻰ‬, ‫ﻛﺮﻭﻧﺰ‬,
ulcerative colitis,multiple sclerosis, celiac disease) ‫ﺣﺴﺎﺳﻴﺔ ﺍﻟﻘﻤﺢ‬, ‫ﺍﻟﺘﺼﻠﺐ ﺍﻟﻠﻮﻳﺤﻰ‬

Have you been diagnosed with any of the following congenital disorder or
hereditary diseases limited to: Cerebral palsy, Sickle cell disorder, Thalassemia, ‫ﻫﻞ ﺗﻢ ﺗﺸﺨﻴﺼﻚ ﺑﺄﻱ ﻣﻦ ﺍﻷﻣﺮﺍﺽ ﺍﻟﻮﺭﺍﺛﻴﺔ ﺃﻭ ﺍﻟﺘﺸﻮﻫﺎﺕ ﺍﻟﺨﻠﻘﻴﺔ ﺍﻟﺘﺎﻟﻴﺔ ﻓﻘﻂ‬
hemophilia, metabolic diseases, Hydrocephalus, spinal muscle atrophy, genital ‫ ﺿﻤﻮﺭ‬،‫ ﺃﺳﺘﺴﻘﺎﺀ ﺍﻟﺮﺃﺱ‬،‫ ﺃﻣﺮﺍﺽ ﺍﻟﺘﻤﺜﻴﻞ ﺍﻟﻐﺬﺍﺋﻲ‬،‫ ﺍﻟﻬﻴﻤﻮﻓﻴﻠﻴﺎ‬،‫ ﺍﻟﺘﻼﺳﻴﻤﻴﺎ‬،‫ﺍﺿﻄﺮﺍﺏ ﺍﻟﺨﻼﻳﺎ ﺍﻟﻤﻨﺠﻠﻴﺔ‬, ‫ﺍﻟﺸﻠﻞ ﺍﻟﺪﻣﺎﻏﻰ‬
malformations, chromosomal abnormalities. Gaucher's disease, G6PD Deficiency, cystic
fibrosis, hemochromatosis, Wilson disease. Polycystic Kidney Disease.
* * ‫ ﻣﺮﺽ ﺍﻟﺘﻜﺴﺮﺍﻟﻔﻮﻟﻰ‬،‫ ﻣﺮﺽ ﻏﻮﺷﺮ‬،‫ ﺃﻣﺮﺍﺽ ﺍﻟﻜﺮﻭﻣﻮﺳﻮﻣﺎﺕ‬،‫ ﺗﺸﻮﻫﺎﺕ ﺍﻷﻋﻀﺎﺀ ﺍﻟﺘﻨﺎﺳﻠﻴﺔ‬،‫ﺍﻟﻌﻀﻼﺕ ﺍﻟﺸﻮﻛﻲ‬
‫ﺗﻜﻴﺲ‬,‫ﻣﺮﺽ ﻭﻳﻠﺴﻮﻥ‬, (‫ ﻣﺮﺽ ﺗﻜﺪﺱ ﺍﻟﺤﺪﻳﺪ )ﻫﻴﻤﻮﻛﺮﻭﻣﺎﺗﻮﺳﻴﺲ‬،‫( ﺍﻟﺘﻠﻴﻒ ﺍﻟﻜﻴﺴﻲ ﻟﻠﺮﺋﺔ‬G6PD)
‫ﺍﻟﻜﻠﻴﺘﻴﻦ ﺍﻟﺨﻠﻔﻰ ﺍﻟﻮﺭﺍﺋﻰ‬

Have you been diagnosed with any of following eye diseases limited to: ،‫ ﻣﻴﺎﺓ ﺯﺭﻗﺎﺀ‬،‫ ﻣﻴﺎﺓ ﺑﻴﻀﺎﺀ‬:‫ﻫﻞ ﺗﻢ ﺗﺸﺨﻴﺼﻚ ﺑﺄﻱ ﻣﻦ ﺃﻣﺮﺍﺽ ﺍﻟﻌﻴﻦ ﺍﻟﺘﺎﻟﻴﺔ ﻓﻘﻂ‬
Cataract, Glaucoma, Retinal diseases. * * ‫ﺃﻣﺮﺍﺽ ﺍﻟﺸﺒﻜﻴﺔ‬
Have you been diagnosed with any of the following bone diseases limited ‫ ﺍﻹﻧﺰﻻﻕ ﺍﻟﻐﻀﺮﻭﻓﻲ‬:‫ﻫﻞ ﺗﻢ ﺗﺸﺨﻴﺼﻚ ﺑﺄﻱ ﻣﻦ ﺃﻣﺮﺍﺽ ﺍﻟﻌﻈﺎﻡ ﺍﻟﺘﺎﻟﻴﺔ ﻓﻘﻂ‬
to:Vertebral disc prolapse (moderate or severe), Scoliosis (moderate or severe)**, or ligament
tears, osteoarthritis (moderate or severe )
* * ‫ﺗﻤﺰﻕ ﺍﻷﺭﺑﻄﺔ‬،‫ﺍﻟﺘﻬﺎﺏ ﺍﻟﻤﻔﺎﺻﻞ‬،‫ﺇﻧﺤﺮﺍﻑ ﺍﻟﻌﻤﻮﺩ ﺍﻟﻔﻘﺮﻱ‬,‫ﺍﻟﺪﻳﺴﻚ‬

Pregnant Female Only ‫ﻟﻸﻧﺜﻰ ﺍﻟﺤﺎﻣﻞ ﻓﻘﻂ‬

‫ﺣﻤﻞ ﺣﺎﻟﻲ ﺟﻨﻴﻦ ﻭﺍﺣﺪ‬
Current Single Pregnancy
* *
‫ﺣﻤﻞ ﺣﺎﻟﻲ ﻣﻊ ﻗﻴﺼﺮﻳﺔ ﺳﺎﺑﻘﺔ‬
Current Single Pregnancy with Previous CS Delivery
* *
‫ﺣﻤﻞ ﺣﺎﻟﻲ ﻣﺘﻌﺪﺩ ﺍﻷﺟﻨﺔ‬
Current Multiple Pregnancy
* *
Expected delivery date .. / .. / .... ‫ﺗﺎﺭﻳﺦ ﺍﻟﻮﻻﺩﺓ ﺍﻟﻤﺘﻮﻗﻊ‬
Employee and dependents details that need to be added ‫ﺑﻴﺎﻧﺎﺕ ﺍﻟﻤﻮﻇﻒ ﻭﺃﻓﺮﺍﺩ ﺍﻟﻌﺎﺋﻠﺔ ﺍﻟﻤﺮﺍﺩ ﺇﺿﺎﻓﺘﻬﻢ‬
In case of a yes answer above, please declare the case in the table below ‫ ﺍﻟﺮﺟﺎﺀ ﺫﻛﺮ ﺍﻟﺤﺎﻟﺔ ﻓﻲ ﺍﻟﺠﺪﻭﻝ ﺃﺩﻧﺎﻩ‬،‫ﻓﻲ ﺣﺎﻟﺔ ﺍﻹﺟﺎﺑﺔ ﺑﻨﻌﻢ ﺃﻋﻼﻩ‬
‫ﺇﺳﻢ ﻣﻘﺪﻡ ﺍﻟﺨﺪﻣﺔ‬ ‫ﺍﻟﺤﺎﻟﺔ‬ ‫ﺭﻗﻢ ﺍﻟﺠﻮﺍﻝ‬ ‫ﺍﻟﻄﻮﻝ‬ ‫ﺍﻟﻮﺯﻥ‬ ‫ﺭﻗﻢ ﺍﻟﻬﻮﻳﺔ‬ ‫ﺍﻟﻘﺮﺍﺑﺔ‬ ‫ﺍﻟﺠﻨﺲ‬ ‫ ﺃﻓﺮﺍﺩ ﺍﻟﻌﺎﺋﻠﺔ‬/ ‫ﺍﺳﻢ ﺍﻟﻤﻮﻇﻒ‬ ‫ﻡ‬
2366249296 Child Female / ‫ ﺃﻧﺜﻰ‬Arwa Ahmad Khaliqullah 1
2
3
4
5
Undertakings : ‫ﺍﻹﻗﺮﺍﺭ ﻭﺍﻟﺘﻔﻮﻳﺾ‬
1- I hereby undertake that all the above information is correct and the acceptance of my ‫ﻭﺍﻟﻤﻌﻠﻮﻣﺎﺕ ﺍﻟﻤﺬﻛﻮﺭﺓ ﺃﻋﻼﻩ ﻛﺎﻣﻠﺔ ﻭﺻﺤﻴﺤﺔ ﻭﺑﻨﺎﺀ ﻋﻠﻴﻪ ﻓﺈﻥ ﻗﺒﻮﻝ ﺍﻟﻄﻠﺐ ﺳﻴﺘﻢ‬: ‫ ﺃﻗﺮ ﺃﻥ ﺍﻟﺒﻴﺎﻧﺎﺕ‬-1
enrollment will be on the basis of such information and that Malath Cooperative Insurance ‫ﻋﻠﻰ ﺃﺳﺎﺱ ﻫﺬﻩ ﺍﻟﺒﻴﺎﻧﺎﺕ ﻭﺃﻥ ﺷﺮﻛﺔ ﻣﻼﺫ ﻟﻠﺘﺄﻣﻴﻦ ﺍﻟﺘﻌﺎﻭﻧﻲ ﻟﻬﺎ ﺍﻟﺤﻖ ﻓﻲ ﺍﻻﺗﺼﺎﻝ ﺑﺎﻟﻤﺴﺘﺸﻔﻴﺎﺕ ﺍﻟﺘﻲ‬
Company has the right to contact the hospital(s) I deal with to collect any ‫ﺃﺗﻌﺎﻣﻞ ﻣﻌﻬﺎ ﻟﺘﺰﻭﻳﺪﻫﺎ ﺑﺄﻱ ﻣﻌﻠﻮﻣﺎﺕ ﻃﺒﻴﺔ ﻗﺪ ﺗﺤﺘﺎﺝ ﺇﻟﻴﻬﺎ ﻟﺘﻘﻴﻴﻢ ﺍﻟﻤﺨﺎﻃﺮ‬
medical information needed to assess the risk(s).

2- I agree that Malath Cooperative Insurance Company has the right to reject the ‫ ﺃﻭﺍﻓﻖ ﻋﻠﻰ ﺃﺣﻘﻴﺔ ﺷﺮﻛﺔ ﻣﻼﺫ ﻟﻠﺘﺄﻣﻴﻦ ﻓﻲ ﺭﻓﺾ ﺍﻟﻤﻄﺎﻟﺒﺔ ﺃﻭ ﺍﻟﺘﻐﻄﻴﺔ ﻛﻠﻴﺎ ﻋﻨﺪ ﻋﺪﻡ ﺍﻹﻓﺼﺎﺡ ﻋﻦ ﻭﺟﻮﺩ ﺃﻱ ﻣﻦ ﺍﻟﺤﺎﻻﺕ‬-2
coverage/claims in full in case of no declaration of any cases prior to the contractual date or ‫ﺍﻟﻤﺬﻛﻮﺭﺓ ﺃﻋﻼﻩ ﺍﻟﺘﻲ ﻧﺸﺄﺕ ﻗﺒﻞ ﺗﺎﺭﻳﺦ ﺍﻟﺘﻌﺎﻗﺪ ﺃﻭ ﻗﺒﻞ ﺗﺴﺠﻴﻞ ﺃﻭ ﺇﺿﺎﻓﺔ ﻋﻀﻮ ﺧﻼﻝ ﻓﺘﺮﺓ ﺳﺮﻳﺎﻥ ﺍﻟﻌﻘﺪ‬
before enrolling or adding a new member during the contract.

3- I hereby confirm reading and understanding all points presented in this form and I agree that ‫ ﺃﻗﺮﺑﺄﻧﻲ ﻗﺪ ﻗﺮﺃﺕ ﻭﻓﻬﻤﺖ ﺟﻤﻴﻊ ﻣﺎ ﺟﺎﺀ ﻓﻲ ﻫﺬﺍ ﺍﻟﻨﻤﻮﺫﺝ ﻛﻤﺎ ﺃﺗﻌﻬﺪ ﺑﺄﻥ ﻋﺪﻡ ﺇﺷﺎﺭﺗﻲ ﺃﻣﺎﻡ ﺃﻱ ﻣﻦ‬-3
not marking any case is understood as “Nothing requires declaration” and I sign on these ‫ﺍﻟﺤﺎﻻﺕ ﺍﻟﻤﺬﻛﻮﺭﺓ ﺃﻋﻼﻩ ﻳﻌﺘﺒﺮ ﺑﻤﺜﺎﺑﺔ ﻧﻔﻲ ﻭﺟﻮﺩ ﻣﺎﻳﺴﺘﺤﻖ ﺍﻹﻓﺼﺎﺡ ﻋﻨﻪ ﻭﻋﻠﻴﻪ ﺃﻭﻗﻊ‬
basis.
4- Failure to fill the weight and height information will result in refusal to cover
the cost of obesity surgery. ‫ ﻋﺪﻡ ﺗﻌﺒﺌﺔ ﺑﻴﺎﻧﺎﺕ ﺍﻟﻄﻮﻝ ﻭﺍﻟﻮﺯﻥ ﺳﻴﺆﺩﻱ ﺇﻟﻰ ﺭﻓﺾ ﺗﻐﻄﻴﺔ ﺗﻜﺎﻟﻴﻒ ﻋﻤﻠﻴﺔ ﺟﺮﺍﺣﺔ ﺍﻟﺴﻤﻨﺔ ﺍﻟﻤﻔﺮﻃﺔ‬-4

Entity's stamp ‫ﺧﺘﻢ ﺟﻬﺔ ﺍﻟﻌﻤﻞ‬ Insured Signature ‫ﺗﻮﻗﻴﻊ ﺍﻟﻤﻮﻇﻒ‬ Date ‫ﺍﻟﺘﺎﺭﻳﺦ‬
.. / .. / ....

New_Health_Insurance.rdf Page 19 of 39 V.20 13-DEC-2023 01:30 PM

 ‫ﻧﻤﻮﺫﺝ ﺍﻻﻓﺼﺎﺡ ﺍﻟﻄﺒﻲ ﺍﻟﻤﻮﺣﺪ‬
Unified Medical Declaration Form
Product Code: A-MLTH-2-C-08-014
Dear Insured: ‫ﻋﺰﻳﺰﻱ ﺍﻟﻤﺆﻣﻦ ﻟﻪ‬
Please Fill out the form correctly for the purpose of pricing and to ensured that you and your ‫ﻧﺄﻣﻞ ﻗﻴﺎﻣﻚ ﺑﺘﻌﺒﺌﺔ ﻫﺬﺍ ﺍﻟﻨﻤﻮﺫﺝ ﺑﺎﻟﺸﻜﻞ ﺍﻟﺼﺤﻴﺢ ﻟﻐﺮﺽ ﺍﻟﺘﺴﻌﻴﺮ ﻭﻟﻀﻤﺎﻥ ﺣﺼﻮﻟﻚ ﻭﺃﻓﺮﺍﺩ ﺃﺳﺮﺗﻚ ﻋﻠﻰ ﺧﺪﻣﺎﺕ‬
family receive health care services as required according to your unfied policy benefit ‫ﺍﻟﺮﻋﺎﻳﺔ ﺍﻟﺼﺤﻴﺔ ﺑﺎﻟﺸﻜﻞ ﺍﻟﻤﻄﻠﻮﺏ ﺣﺴﺐ ﻣﻨﺎﻓﻊ ﺍﻟﻮﺛﻴﻘﺔ ﺍﻟﻤﻮﺣﺪﺓ‬

Addition ‫ﺇﺿﺎﻓﺔ‬ New ‫ﺟﺪﻳﺪ‬ Type ‫ﻧﻮﻉ ﺍﻟﻄﻠﺐ‬

CR No 7011507360 ‫ﺍﻟﺴﺠﻞ ﺍﻟﺘﺠﺎﺭﻱ‬ Entity Name HADDAJ AL HIJAZ EST ‫ﺃﺳﻢ ﺍﻟﻤﻨﺸﺄﺓ‬
Mobile No 0553220574 ‫ﺭﻗﻢ ﺍﻟﺠﻮﺍﻝ‬ Eyad Ahmad Khaliqullah ‫ﺍﺳﻢ ﺍﻟﻤﻮﻇﻒ‬
ID Number 2 4 4 5 7 0 2 5 9 6 ‫ﺭﻗﻢ ﺍﻟﻬﻮﻳﺔ‬
Male / ‫ﺫﻛﺮ‬ India
Gender ‫ ﺍﻟﺠﻨﺲ‬Nationality ‫ ﺍﻟﺠﻨﺴﻴﺔ‬Marital status Married * ‫ﻣﺘﺰﻭﺝ‬ Single R ‫ﺃﻋﺰﺏ‬ ‫ﺍﻟﺤﺎﻟﺔ ﺍﻻﺟﺘﻤﺎﻋﻴﺔ‬
Please declare any of the below cases by marking P under the word Yes ‫ ﻓﻲ ﺍﻟﻤﺮﺑﻊ ﺗﺤﺖ ﻛﻠﻤﺔ ﻧﻌﻢ‬P ‫ﻳﺮﺟﻰ ﺍﻹﻓﺼﺎﺡ ﻋﻦ ﻭﺟﻮﺩ ﺃﻱ ﻣﻦ ﺍﻟﺤﺎﻻﺕ ﺍﺩﻧﺎﻩ ﺑﻮﺿﻊ ﺇﺷﺎﺭﺓ‬
"Below Undeclared Medical Case May Not Be Covered" No / ‫ﻻ‬ Yes / ‫ﻧﻌـﻢ‬ "‫"ﻟﻦ ﺗﺘﻢ ﺍﻟﺘﻐﻄﻴﺔ ﺍﻟﺘﺄﻣﻴﻨﻴﺔ ﻟﻠﺤﺎﻻﺕ ﺃﺩﻧﺎﻩ ﻓﻰ ﺣﺎﻝ ﻋﺪﻡ ﺍﻹﻓﺼﺎﺡ ﻋﻨﻬﺎ‬
Any hospital admission during last 12 months. ‫ ﺷﻬﺮ‬12 ‫ﻫﻞ ﺗﻢ ﺍﻟﺘﻨﻮﻳﻢ ﺑﺎﻟﻤﺴﺘﺸﻔﻰ ﺧﻼﻝ ﺃﺧﺮ‬
"Admission: registering as an admitted patient at the hospital until the following morning "
* * " ‫ ﺗﺴﺠﻴﻞ ﺍﻟﺸﺨﺺ ﺍﻟﻤﺆﻣﻦ ﻟﻪ ﻛﻤﺮﻳﺾ ﻣﻨﻮﻡ ﻓﻲ ﺍﻟﻤﺴﺘﺸﻔﻰ ﺣﺘﻰ ﺻﺒﺎﺡ ﺍﻟﻴﻮﻡ ﺍﻟﺘﺎﻟﻲ‬: ‫" ﺍﻟﺘﻨﻮﻳﻢ‬

Have you been diagnosed with any of the following chronic disease limited ‫ﻫﻞ ﺗﻢ ﺗﺸﺨﻴﺼﻚ ﺑﺄﻯ ﻣﻦ ﺍﻷﻣﺮﺍﺽ ﺍﻟﺘﺎﻟﻴﺔ ﻓﻘﻂ‬
to:Autism, listed Benign Tumor (Breast tumors, fibroid uterus, benign prostatic hyperplasia, ‫ﺃﻭﺭﺍﻡ ﺃﻭ‬,‫ﺗﻀﺨﻢ ﺍﻟﺒﺮﻭﺳﺘﺎﺗﺎ ﺍﻟﺤﻤﻴﺪ‬,‫ ﺃﻭﺭﺍﻡ ﺍﻟﺮﺣﻢ ﺍﻟﻠﻴﻔﻰ‬, ‫ﺍﻻﻭﺭﺍﻡ ﺍﻟﺤﻤﻴﺪﺓ ﺍﻟﺘﺎﻟﻴﺔ )ﺃﻭﺭﺍﻡ ﺍﻟﺜﺪﻯ‬,‫ﺍﻷﻭﺭﺍﻡ ﺍﻟﺴﺮﻃﺎﻧﻴﺔ‬,‫ﺍﻟﺘﻮﺣﺪ‬
thyroid goiter and parathyroid glands, live tumors, colon tumors). Malignant tumors, listed ‫ﺃﻣﺮﺍﺽ ﺍﻟﻘﻠﺐ ﺍﻟﺘﺎﻟﻴﺔ)ﺃﻣﺮﺍﺽ ﺷﺮﺍﻳﻴﻦ ﻭﺻﻤﺎﻣﺎﺕ ﺗﻀﺨﻢ ﺍﻟﻐﺪﺓ ﺍﻟﺪﺭﻗﻴﺔ‬, (‫ﺃﻭﺭﺍﻡ ﺍﻟﻘﻮﻟﻮﻥ‬, ‫ﻭﺃﻭﺭﺍﻡ ﺍﻻﻟﻜﺒﺪ‬,‫ﻭ ﺍﻟﺠﺎﺭ ﺍﻟﺪﺭﻗﻴﺔ‬
Cardiac diseases coronary and valve heart diseases, heart failure, cardiac fibrillation
myocardial infraction, heart clots). Chronic Hepatitis C. Gallstones Sever Kidney failure (stage
* * ‫ﺍﻻﻟﺘﻬﺎﺏ ﺍﻟﻜﺒﺪﻯ ﺍﻟﻔﻴﺮﻭﺳﻰ ﺍﻟﻤﺰﻣﻦ‬.( ‫ﺍﻟﺮﺟﻔﺎﻥ ﺍﻟﻘﻠﺒﻰ ﻭﺟﻠﻄﺎﺕ ﺍﻟﻘﻠﺐ‬, ‫ﻓﺸﻞ ﻋﻀﻠﺔ ﺍﻟﻘﻠﺐ‬, ‫ﺣﺼﻮﺍﺕ ﺍﻟﻤﺮﺍﺭﺓ ﺍﻟﻘﻠﺐ‬, ‫ﺝ ﻭﺳﻰ‬
,‫ ﺍﻟﺘﺮﺷﻴﺢ ﺍﻟﻜﻠﻮﻯ ﺃﻗﻞ ﻣﻦ‬,‫ ﺍﻟﻔﺸﻞ ﺍﻟﻜﻠﻮﻯﺍﻟﺸﺪﻳﺪ )ﺍﻟﻤﺮﺣﻠﺔ ﺍﻟﺨﺎﻣﺴﺔ ﻣﻦ ﺍﻣﺮﺍﺽ ﺍﻟﻜﻠﻰ ﺍﻟﺘﻰ ﺗﺴﺘﺪﻋﻰ ﺍﻟﻐﺴﻴﻞ ﺍﻟﻜﻠﻮﻯ‬15
5 Requiring dialysis, clearance of less tha 15 ml/ minute*). Urinary tract ‫ﻣﺮﺽ‬, ‫ﺩﻗﻴﻘﺔ(ﺣﺼﻮﺍﺕ ﺍﻟﻤﺴﺎﻟﻚ ﺍﻟﺒﻮﻟﻴﺔﺃﻣﺮﺍﺽ ﺍﻟﻤﻨﺎﻋﺔ ﺍﻟﺘﺎﻟﻴﺔ )ﺍﻟﺬﺋﺒﺔ ﺍﻟﺤﻤﺮﺍﺀﻭﺍﻟﺘﻬﺎﺏ ﺍﻟﻤﻔﺎﺻﻞ ﺍﻟﺮﻭﻣﺎﺗﻴﺰﻣﻴﺔﻭ ﺍﻟﺼﺪﻓﻴﺔ‬/‫ﻣﻞ‬
stones, hernias. Autoimmune disease (lupus, rheumatoid arthritis, psoriasis, Crohn's disease, ‫ﺍﻟﺘﻬﺎﺏ ﺍﻟﻘﻮﻟﻮﻥ ﺍﻟﺘﻘﺮﺣﻰ‬, ‫ﻛﺮﻭﻧﺰ‬,
ulcerative colitis,multiple sclerosis, celiac disease) ‫ﺣﺴﺎﺳﻴﺔ ﺍﻟﻘﻤﺢ‬, ‫ﺍﻟﺘﺼﻠﺐ ﺍﻟﻠﻮﻳﺤﻰ‬

Have you been diagnosed with any of the following congenital disorder or
hereditary diseases limited to: Cerebral palsy, Sickle cell disorder, Thalassemia, ‫ﻫﻞ ﺗﻢ ﺗﺸﺨﻴﺼﻚ ﺑﺄﻱ ﻣﻦ ﺍﻷﻣﺮﺍﺽ ﺍﻟﻮﺭﺍﺛﻴﺔ ﺃﻭ ﺍﻟﺘﺸﻮﻫﺎﺕ ﺍﻟﺨﻠﻘﻴﺔ ﺍﻟﺘﺎﻟﻴﺔ ﻓﻘﻂ‬
hemophilia, metabolic diseases, Hydrocephalus, spinal muscle atrophy, genital ‫ ﺿﻤﻮﺭ‬،‫ ﺃﺳﺘﺴﻘﺎﺀ ﺍﻟﺮﺃﺱ‬،‫ ﺃﻣﺮﺍﺽ ﺍﻟﺘﻤﺜﻴﻞ ﺍﻟﻐﺬﺍﺋﻲ‬،‫ ﺍﻟﻬﻴﻤﻮﻓﻴﻠﻴﺎ‬،‫ ﺍﻟﺘﻼﺳﻴﻤﻴﺎ‬،‫ﺍﺿﻄﺮﺍﺏ ﺍﻟﺨﻼﻳﺎ ﺍﻟﻤﻨﺠﻠﻴﺔ‬, ‫ﺍﻟﺸﻠﻞ ﺍﻟﺪﻣﺎﻏﻰ‬
malformations, chromosomal abnormalities. Gaucher's disease, G6PD Deficiency, cystic
fibrosis, hemochromatosis, Wilson disease. Polycystic Kidney Disease.
* * ‫ ﻣﺮﺽ ﺍﻟﺘﻜﺴﺮﺍﻟﻔﻮﻟﻰ‬،‫ ﻣﺮﺽ ﻏﻮﺷﺮ‬،‫ ﺃﻣﺮﺍﺽ ﺍﻟﻜﺮﻭﻣﻮﺳﻮﻣﺎﺕ‬،‫ ﺗﺸﻮﻫﺎﺕ ﺍﻷﻋﻀﺎﺀ ﺍﻟﺘﻨﺎﺳﻠﻴﺔ‬،‫ﺍﻟﻌﻀﻼﺕ ﺍﻟﺸﻮﻛﻲ‬
‫ﺗﻜﻴﺲ‬,‫ﻣﺮﺽ ﻭﻳﻠﺴﻮﻥ‬, (‫ ﻣﺮﺽ ﺗﻜﺪﺱ ﺍﻟﺤﺪﻳﺪ )ﻫﻴﻤﻮﻛﺮﻭﻣﺎﺗﻮﺳﻴﺲ‬،‫( ﺍﻟﺘﻠﻴﻒ ﺍﻟﻜﻴﺴﻲ ﻟﻠﺮﺋﺔ‬G6PD)
‫ﺍﻟﻜﻠﻴﺘﻴﻦ ﺍﻟﺨﻠﻔﻰ ﺍﻟﻮﺭﺍﺋﻰ‬

Have you been diagnosed with any of following eye diseases limited to: ،‫ ﻣﻴﺎﺓ ﺯﺭﻗﺎﺀ‬،‫ ﻣﻴﺎﺓ ﺑﻴﻀﺎﺀ‬:‫ﻫﻞ ﺗﻢ ﺗﺸﺨﻴﺼﻚ ﺑﺄﻱ ﻣﻦ ﺃﻣﺮﺍﺽ ﺍﻟﻌﻴﻦ ﺍﻟﺘﺎﻟﻴﺔ ﻓﻘﻂ‬
Cataract, Glaucoma, Retinal diseases. * * ‫ﺃﻣﺮﺍﺽ ﺍﻟﺸﺒﻜﻴﺔ‬
Have you been diagnosed with any of the following bone diseases limited ‫ ﺍﻹﻧﺰﻻﻕ ﺍﻟﻐﻀﺮﻭﻓﻲ‬:‫ﻫﻞ ﺗﻢ ﺗﺸﺨﻴﺼﻚ ﺑﺄﻱ ﻣﻦ ﺃﻣﺮﺍﺽ ﺍﻟﻌﻈﺎﻡ ﺍﻟﺘﺎﻟﻴﺔ ﻓﻘﻂ‬
to:Vertebral disc prolapse (moderate or severe), Scoliosis (moderate or severe)**, or ligament
tears, osteoarthritis (moderate or severe )
* * ‫ﺗﻤﺰﻕ ﺍﻷﺭﺑﻄﺔ‬،‫ﺍﻟﺘﻬﺎﺏ ﺍﻟﻤﻔﺎﺻﻞ‬،‫ﺇﻧﺤﺮﺍﻑ ﺍﻟﻌﻤﻮﺩ ﺍﻟﻔﻘﺮﻱ‬,‫ﺍﻟﺪﻳﺴﻚ‬

Pregnant Female Only ‫ﻟﻸﻧﺜﻰ ﺍﻟﺤﺎﻣﻞ ﻓﻘﻂ‬

‫ﺣﻤﻞ ﺣﺎﻟﻲ ﺟﻨﻴﻦ ﻭﺍﺣﺪ‬
Current Single Pregnancy
* *
‫ﺣﻤﻞ ﺣﺎﻟﻲ ﻣﻊ ﻗﻴﺼﺮﻳﺔ ﺳﺎﺑﻘﺔ‬
Current Single Pregnancy with Previous CS Delivery
* *
‫ﺣﻤﻞ ﺣﺎﻟﻲ ﻣﺘﻌﺪﺩ ﺍﻷﺟﻨﺔ‬
Current Multiple Pregnancy
* *
Expected delivery date .. / .. / .... ‫ﺗﺎﺭﻳﺦ ﺍﻟﻮﻻﺩﺓ ﺍﻟﻤﺘﻮﻗﻊ‬
Employee and dependents details that need to be added ‫ﺑﻴﺎﻧﺎﺕ ﺍﻟﻤﻮﻇﻒ ﻭﺃﻓﺮﺍﺩ ﺍﻟﻌﺎﺋﻠﺔ ﺍﻟﻤﺮﺍﺩ ﺇﺿﺎﻓﺘﻬﻢ‬
In case of a yes answer above, please declare the case in the table below ‫ ﺍﻟﺮﺟﺎﺀ ﺫﻛﺮ ﺍﻟﺤﺎﻟﺔ ﻓﻲ ﺍﻟﺠﺪﻭﻝ ﺃﺩﻧﺎﻩ‬،‫ﻓﻲ ﺣﺎﻟﺔ ﺍﻹﺟﺎﺑﺔ ﺑﻨﻌﻢ ﺃﻋﻼﻩ‬
‫ﺇﺳﻢ ﻣﻘﺪﻡ ﺍﻟﺨﺪﻣﺔ‬ ‫ﺍﻟﺤﺎﻟﺔ‬ ‫ﺭﻗﻢ ﺍﻟﺠﻮﺍﻝ‬ ‫ﺍﻟﻄﻮﻝ‬ ‫ﺍﻟﻮﺯﻥ‬ ‫ﺭﻗﻢ ﺍﻟﻬﻮﻳﺔ‬ ‫ﺍﻟﻘﺮﺍﺑﺔ‬ ‫ﺍﻟﺠﻨﺲ‬ ‫ ﺃﻓﺮﺍﺩ ﺍﻟﻌﺎﺋﻠﺔ‬/ ‫ﺍﺳﻢ ﺍﻟﻤﻮﻇﻒ‬ ‫ﻡ‬
2445702596 Child Male / ‫ ﺫﻛﺮ‬Eyad Ahmad Khaliqullah 1
2
3
4
5
Undertakings : ‫ﺍﻹﻗﺮﺍﺭ ﻭﺍﻟﺘﻔﻮﻳﺾ‬
1- I hereby undertake that all the above information is correct and the acceptance of my ‫ﻭﺍﻟﻤﻌﻠﻮﻣﺎﺕ ﺍﻟﻤﺬﻛﻮﺭﺓ ﺃﻋﻼﻩ ﻛﺎﻣﻠﺔ ﻭﺻﺤﻴﺤﺔ ﻭﺑﻨﺎﺀ ﻋﻠﻴﻪ ﻓﺈﻥ ﻗﺒﻮﻝ ﺍﻟﻄﻠﺐ ﺳﻴﺘﻢ‬: ‫ ﺃﻗﺮ ﺃﻥ ﺍﻟﺒﻴﺎﻧﺎﺕ‬-1
enrollment will be on the basis of such information and that Malath Cooperative Insurance ‫ﻋﻠﻰ ﺃﺳﺎﺱ ﻫﺬﻩ ﺍﻟﺒﻴﺎﻧﺎﺕ ﻭﺃﻥ ﺷﺮﻛﺔ ﻣﻼﺫ ﻟﻠﺘﺄﻣﻴﻦ ﺍﻟﺘﻌﺎﻭﻧﻲ ﻟﻬﺎ ﺍﻟﺤﻖ ﻓﻲ ﺍﻻﺗﺼﺎﻝ ﺑﺎﻟﻤﺴﺘﺸﻔﻴﺎﺕ ﺍﻟﺘﻲ‬
Company has the right to contact the hospital(s) I deal with to collect any ‫ﺃﺗﻌﺎﻣﻞ ﻣﻌﻬﺎ ﻟﺘﺰﻭﻳﺪﻫﺎ ﺑﺄﻱ ﻣﻌﻠﻮﻣﺎﺕ ﻃﺒﻴﺔ ﻗﺪ ﺗﺤﺘﺎﺝ ﺇﻟﻴﻬﺎ ﻟﺘﻘﻴﻴﻢ ﺍﻟﻤﺨﺎﻃﺮ‬
medical information needed to assess the risk(s).

2- I agree that Malath Cooperative Insurance Company has the right to reject the ‫ ﺃﻭﺍﻓﻖ ﻋﻠﻰ ﺃﺣﻘﻴﺔ ﺷﺮﻛﺔ ﻣﻼﺫ ﻟﻠﺘﺄﻣﻴﻦ ﻓﻲ ﺭﻓﺾ ﺍﻟﻤﻄﺎﻟﺒﺔ ﺃﻭ ﺍﻟﺘﻐﻄﻴﺔ ﻛﻠﻴﺎ ﻋﻨﺪ ﻋﺪﻡ ﺍﻹﻓﺼﺎﺡ ﻋﻦ ﻭﺟﻮﺩ ﺃﻱ ﻣﻦ ﺍﻟﺤﺎﻻﺕ‬-2
coverage/claims in full in case of no declaration of any cases prior to the contractual date or ‫ﺍﻟﻤﺬﻛﻮﺭﺓ ﺃﻋﻼﻩ ﺍﻟﺘﻲ ﻧﺸﺄﺕ ﻗﺒﻞ ﺗﺎﺭﻳﺦ ﺍﻟﺘﻌﺎﻗﺪ ﺃﻭ ﻗﺒﻞ ﺗﺴﺠﻴﻞ ﺃﻭ ﺇﺿﺎﻓﺔ ﻋﻀﻮ ﺧﻼﻝ ﻓﺘﺮﺓ ﺳﺮﻳﺎﻥ ﺍﻟﻌﻘﺪ‬
before enrolling or adding a new member during the contract.

3- I hereby confirm reading and understanding all points presented in this form and I agree that ‫ ﺃﻗﺮﺑﺄﻧﻲ ﻗﺪ ﻗﺮﺃﺕ ﻭﻓﻬﻤﺖ ﺟﻤﻴﻊ ﻣﺎ ﺟﺎﺀ ﻓﻲ ﻫﺬﺍ ﺍﻟﻨﻤﻮﺫﺝ ﻛﻤﺎ ﺃﺗﻌﻬﺪ ﺑﺄﻥ ﻋﺪﻡ ﺇﺷﺎﺭﺗﻲ ﺃﻣﺎﻡ ﺃﻱ ﻣﻦ‬-3
not marking any case is understood as “Nothing requires declaration” and I sign on these ‫ﺍﻟﺤﺎﻻﺕ ﺍﻟﻤﺬﻛﻮﺭﺓ ﺃﻋﻼﻩ ﻳﻌﺘﺒﺮ ﺑﻤﺜﺎﺑﺔ ﻧﻔﻲ ﻭﺟﻮﺩ ﻣﺎﻳﺴﺘﺤﻖ ﺍﻹﻓﺼﺎﺡ ﻋﻨﻪ ﻭﻋﻠﻴﻪ ﺃﻭﻗﻊ‬
basis.
4- Failure to fill the weight and height information will result in refusal to cover
the cost of obesity surgery. ‫ ﻋﺪﻡ ﺗﻌﺒﺌﺔ ﺑﻴﺎﻧﺎﺕ ﺍﻟﻄﻮﻝ ﻭﺍﻟﻮﺯﻥ ﺳﻴﺆﺩﻱ ﺇﻟﻰ ﺭﻓﺾ ﺗﻐﻄﻴﺔ ﺗﻜﺎﻟﻴﻒ ﻋﻤﻠﻴﺔ ﺟﺮﺍﺣﺔ ﺍﻟﺴﻤﻨﺔ ﺍﻟﻤﻔﺮﻃﺔ‬-4

Entity's stamp ‫ﺧﺘﻢ ﺟﻬﺔ ﺍﻟﻌﻤﻞ‬ Insured Signature ‫ﺗﻮﻗﻴﻊ ﺍﻟﻤﻮﻇﻒ‬ Date ‫ﺍﻟﺘﺎﺭﻳﺦ‬
.. / .. / ....

New_Health_Insurance.rdf Page 20 of 39 V.20 13-DEC-2023 01:30 PM

 ‫ﻧﻤﻮﺫﺝ ﺍﻻﻓﺼﺎﺡ ﺍﻟﻄﺒﻲ ﺍﻟﻤﻮﺣﺪ‬
Unified Medical Declaration Form
Product Code: A-MLTH-2-C-08-014
Dear Insured: ‫ﻋﺰﻳﺰﻱ ﺍﻟﻤﺆﻣﻦ ﻟﻪ‬
Please Fill out the form correctly for the purpose of pricing and to ensured that you and your ‫ﻧﺄﻣﻞ ﻗﻴﺎﻣﻚ ﺑﺘﻌﺒﺌﺔ ﻫﺬﺍ ﺍﻟﻨﻤﻮﺫﺝ ﺑﺎﻟﺸﻜﻞ ﺍﻟﺼﺤﻴﺢ ﻟﻐﺮﺽ ﺍﻟﺘﺴﻌﻴﺮ ﻭﻟﻀﻤﺎﻥ ﺣﺼﻮﻟﻚ ﻭﺃﻓﺮﺍﺩ ﺃﺳﺮﺗﻚ ﻋﻠﻰ ﺧﺪﻣﺎﺕ‬
family receive health care services as required according to your unfied policy benefit ‫ﺍﻟﺮﻋﺎﻳﺔ ﺍﻟﺼﺤﻴﺔ ﺑﺎﻟﺸﻜﻞ ﺍﻟﻤﻄﻠﻮﺏ ﺣﺴﺐ ﻣﻨﺎﻓﻊ ﺍﻟﻮﺛﻴﻘﺔ ﺍﻟﻤﻮﺣﺪﺓ‬

Addition ‫ﺇﺿﺎﻓﺔ‬ New ‫ﺟﺪﻳﺪ‬ Type ‫ﻧﻮﻉ ﺍﻟﻄﻠﺐ‬

CR No 7011507360 ‫ﺍﻟﺴﺠﻞ ﺍﻟﺘﺠﺎﺭﻱ‬ Entity Name HADDAJ AL HIJAZ EST ‫ﺃﺳﻢ ﺍﻟﻤﻨﺸﺄﺓ‬
Mobile No 0544451736 ‫ﺭﻗﻢ ﺍﻟﺠﻮﺍﻝ‬ Abdullah Khaliqullah ‫ﺍﺳﻢ ﺍﻟﻤﻮﻇﻒ‬
ID Number 2 0 1 6 7 6 8 6 7 9 ‫ﺭﻗﻢ ﺍﻟﻬﻮﻳﺔ‬
Male / ‫ﺫﻛﺮ‬ India
Gender ‫ ﺍﻟﺠﻨﺲ‬Nationality ‫ ﺍﻟﺠﻨﺴﻴﺔ‬Marital status Married R ‫ﻣﺘﺰﻭﺝ‬ Single * ‫ﺃﻋﺰﺏ‬ ‫ﺍﻟﺤﺎﻟﺔ ﺍﻻﺟﺘﻤﺎﻋﻴﺔ‬
Please declare any of the below cases by marking P under the word Yes ‫ ﻓﻲ ﺍﻟﻤﺮﺑﻊ ﺗﺤﺖ ﻛﻠﻤﺔ ﻧﻌﻢ‬P ‫ﻳﺮﺟﻰ ﺍﻹﻓﺼﺎﺡ ﻋﻦ ﻭﺟﻮﺩ ﺃﻱ ﻣﻦ ﺍﻟﺤﺎﻻﺕ ﺍﺩﻧﺎﻩ ﺑﻮﺿﻊ ﺇﺷﺎﺭﺓ‬
"Below Undeclared Medical Case May Not Be Covered" No / ‫ﻻ‬ Yes / ‫ﻧﻌـﻢ‬ "‫"ﻟﻦ ﺗﺘﻢ ﺍﻟﺘﻐﻄﻴﺔ ﺍﻟﺘﺄﻣﻴﻨﻴﺔ ﻟﻠﺤﺎﻻﺕ ﺃﺩﻧﺎﻩ ﻓﻰ ﺣﺎﻝ ﻋﺪﻡ ﺍﻹﻓﺼﺎﺡ ﻋﻨﻬﺎ‬
Any hospital admission during last 12 months. ‫ ﺷﻬﺮ‬12 ‫ﻫﻞ ﺗﻢ ﺍﻟﺘﻨﻮﻳﻢ ﺑﺎﻟﻤﺴﺘﺸﻔﻰ ﺧﻼﻝ ﺃﺧﺮ‬
"Admission: registering as an admitted patient at the hospital until the following morning "
* * " ‫ ﺗﺴﺠﻴﻞ ﺍﻟﺸﺨﺺ ﺍﻟﻤﺆﻣﻦ ﻟﻪ ﻛﻤﺮﻳﺾ ﻣﻨﻮﻡ ﻓﻲ ﺍﻟﻤﺴﺘﺸﻔﻰ ﺣﺘﻰ ﺻﺒﺎﺡ ﺍﻟﻴﻮﻡ ﺍﻟﺘﺎﻟﻲ‬: ‫" ﺍﻟﺘﻨﻮﻳﻢ‬

Have you been diagnosed with any of the following chronic disease limited ‫ﻫﻞ ﺗﻢ ﺗﺸﺨﻴﺼﻚ ﺑﺄﻯ ﻣﻦ ﺍﻷﻣﺮﺍﺽ ﺍﻟﺘﺎﻟﻴﺔ ﻓﻘﻂ‬
to:Autism, listed Benign Tumor (Breast tumors, fibroid uterus, benign prostatic hyperplasia, ‫ﺃﻭﺭﺍﻡ ﺃﻭ‬,‫ﺗﻀﺨﻢ ﺍﻟﺒﺮﻭﺳﺘﺎﺗﺎ ﺍﻟﺤﻤﻴﺪ‬,‫ ﺃﻭﺭﺍﻡ ﺍﻟﺮﺣﻢ ﺍﻟﻠﻴﻔﻰ‬, ‫ﺍﻻﻭﺭﺍﻡ ﺍﻟﺤﻤﻴﺪﺓ ﺍﻟﺘﺎﻟﻴﺔ )ﺃﻭﺭﺍﻡ ﺍﻟﺜﺪﻯ‬,‫ﺍﻷﻭﺭﺍﻡ ﺍﻟﺴﺮﻃﺎﻧﻴﺔ‬,‫ﺍﻟﺘﻮﺣﺪ‬
thyroid goiter and parathyroid glands, live tumors, colon tumors). Malignant tumors, listed ‫ﺃﻣﺮﺍﺽ ﺍﻟﻘﻠﺐ ﺍﻟﺘﺎﻟﻴﺔ)ﺃﻣﺮﺍﺽ ﺷﺮﺍﻳﻴﻦ ﻭﺻﻤﺎﻣﺎﺕ ﺗﻀﺨﻢ ﺍﻟﻐﺪﺓ ﺍﻟﺪﺭﻗﻴﺔ‬, (‫ﺃﻭﺭﺍﻡ ﺍﻟﻘﻮﻟﻮﻥ‬, ‫ﻭﺃﻭﺭﺍﻡ ﺍﻻﻟﻜﺒﺪ‬,‫ﻭ ﺍﻟﺠﺎﺭ ﺍﻟﺪﺭﻗﻴﺔ‬
Cardiac diseases coronary and valve heart diseases, heart failure, cardiac fibrillation
myocardial infraction, heart clots). Chronic Hepatitis C. Gallstones Sever Kidney failure (stage
* * ‫ﺍﻻﻟﺘﻬﺎﺏ ﺍﻟﻜﺒﺪﻯ ﺍﻟﻔﻴﺮﻭﺳﻰ ﺍﻟﻤﺰﻣﻦ‬.( ‫ﺍﻟﺮﺟﻔﺎﻥ ﺍﻟﻘﻠﺒﻰ ﻭﺟﻠﻄﺎﺕ ﺍﻟﻘﻠﺐ‬, ‫ﻓﺸﻞ ﻋﻀﻠﺔ ﺍﻟﻘﻠﺐ‬, ‫ﺣﺼﻮﺍﺕ ﺍﻟﻤﺮﺍﺭﺓ ﺍﻟﻘﻠﺐ‬, ‫ﺝ ﻭﺳﻰ‬
,‫ ﺍﻟﺘﺮﺷﻴﺢ ﺍﻟﻜﻠﻮﻯ ﺃﻗﻞ ﻣﻦ‬,‫ ﺍﻟﻔﺸﻞ ﺍﻟﻜﻠﻮﻯﺍﻟﺸﺪﻳﺪ )ﺍﻟﻤﺮﺣﻠﺔ ﺍﻟﺨﺎﻣﺴﺔ ﻣﻦ ﺍﻣﺮﺍﺽ ﺍﻟﻜﻠﻰ ﺍﻟﺘﻰ ﺗﺴﺘﺪﻋﻰ ﺍﻟﻐﺴﻴﻞ ﺍﻟﻜﻠﻮﻯ‬15
5 Requiring dialysis, clearance of less tha 15 ml/ minute*). Urinary tract ‫ﻣﺮﺽ‬, ‫ﺩﻗﻴﻘﺔ(ﺣﺼﻮﺍﺕ ﺍﻟﻤﺴﺎﻟﻚ ﺍﻟﺒﻮﻟﻴﺔﺃﻣﺮﺍﺽ ﺍﻟﻤﻨﺎﻋﺔ ﺍﻟﺘﺎﻟﻴﺔ )ﺍﻟﺬﺋﺒﺔ ﺍﻟﺤﻤﺮﺍﺀﻭﺍﻟﺘﻬﺎﺏ ﺍﻟﻤﻔﺎﺻﻞ ﺍﻟﺮﻭﻣﺎﺗﻴﺰﻣﻴﺔﻭ ﺍﻟﺼﺪﻓﻴﺔ‬/‫ﻣﻞ‬
stones, hernias. Autoimmune disease (lupus, rheumatoid arthritis, psoriasis, Crohn's disease, ‫ﺍﻟﺘﻬﺎﺏ ﺍﻟﻘﻮﻟﻮﻥ ﺍﻟﺘﻘﺮﺣﻰ‬, ‫ﻛﺮﻭﻧﺰ‬,
ulcerative colitis,multiple sclerosis, celiac disease) ‫ﺣﺴﺎﺳﻴﺔ ﺍﻟﻘﻤﺢ‬, ‫ﺍﻟﺘﺼﻠﺐ ﺍﻟﻠﻮﻳﺤﻰ‬

Have you been diagnosed with any of the following congenital disorder or
hereditary diseases limited to: Cerebral palsy, Sickle cell disorder, Thalassemia, ‫ﻫﻞ ﺗﻢ ﺗﺸﺨﻴﺼﻚ ﺑﺄﻱ ﻣﻦ ﺍﻷﻣﺮﺍﺽ ﺍﻟﻮﺭﺍﺛﻴﺔ ﺃﻭ ﺍﻟﺘﺸﻮﻫﺎﺕ ﺍﻟﺨﻠﻘﻴﺔ ﺍﻟﺘﺎﻟﻴﺔ ﻓﻘﻂ‬
hemophilia, metabolic diseases, Hydrocephalus, spinal muscle atrophy, genital ‫ ﺿﻤﻮﺭ‬،‫ ﺃﺳﺘﺴﻘﺎﺀ ﺍﻟﺮﺃﺱ‬،‫ ﺃﻣﺮﺍﺽ ﺍﻟﺘﻤﺜﻴﻞ ﺍﻟﻐﺬﺍﺋﻲ‬،‫ ﺍﻟﻬﻴﻤﻮﻓﻴﻠﻴﺎ‬،‫ ﺍﻟﺘﻼﺳﻴﻤﻴﺎ‬،‫ﺍﺿﻄﺮﺍﺏ ﺍﻟﺨﻼﻳﺎ ﺍﻟﻤﻨﺠﻠﻴﺔ‬, ‫ﺍﻟﺸﻠﻞ ﺍﻟﺪﻣﺎﻏﻰ‬
malformations, chromosomal abnormalities. Gaucher's disease, G6PD Deficiency, cystic
fibrosis, hemochromatosis, Wilson disease. Polycystic Kidney Disease.
* * ‫ ﻣﺮﺽ ﺍﻟﺘﻜﺴﺮﺍﻟﻔﻮﻟﻰ‬،‫ ﻣﺮﺽ ﻏﻮﺷﺮ‬،‫ ﺃﻣﺮﺍﺽ ﺍﻟﻜﺮﻭﻣﻮﺳﻮﻣﺎﺕ‬،‫ ﺗﺸﻮﻫﺎﺕ ﺍﻷﻋﻀﺎﺀ ﺍﻟﺘﻨﺎﺳﻠﻴﺔ‬،‫ﺍﻟﻌﻀﻼﺕ ﺍﻟﺸﻮﻛﻲ‬
‫ﺗﻜﻴﺲ‬,‫ﻣﺮﺽ ﻭﻳﻠﺴﻮﻥ‬, (‫ ﻣﺮﺽ ﺗﻜﺪﺱ ﺍﻟﺤﺪﻳﺪ )ﻫﻴﻤﻮﻛﺮﻭﻣﺎﺗﻮﺳﻴﺲ‬،‫( ﺍﻟﺘﻠﻴﻒ ﺍﻟﻜﻴﺴﻲ ﻟﻠﺮﺋﺔ‬G6PD)
‫ﺍﻟﻜﻠﻴﺘﻴﻦ ﺍﻟﺨﻠﻔﻰ ﺍﻟﻮﺭﺍﺋﻰ‬

Have you been diagnosed with any of following eye diseases limited to: ،‫ ﻣﻴﺎﺓ ﺯﺭﻗﺎﺀ‬،‫ ﻣﻴﺎﺓ ﺑﻴﻀﺎﺀ‬:‫ﻫﻞ ﺗﻢ ﺗﺸﺨﻴﺼﻚ ﺑﺄﻱ ﻣﻦ ﺃﻣﺮﺍﺽ ﺍﻟﻌﻴﻦ ﺍﻟﺘﺎﻟﻴﺔ ﻓﻘﻂ‬
Cataract, Glaucoma, Retinal diseases. * * ‫ﺃﻣﺮﺍﺽ ﺍﻟﺸﺒﻜﻴﺔ‬
Have you been diagnosed with any of the following bone diseases limited ‫ ﺍﻹﻧﺰﻻﻕ ﺍﻟﻐﻀﺮﻭﻓﻲ‬:‫ﻫﻞ ﺗﻢ ﺗﺸﺨﻴﺼﻚ ﺑﺄﻱ ﻣﻦ ﺃﻣﺮﺍﺽ ﺍﻟﻌﻈﺎﻡ ﺍﻟﺘﺎﻟﻴﺔ ﻓﻘﻂ‬
to:Vertebral disc prolapse (moderate or severe), Scoliosis (moderate or severe)**, or ligament
tears, osteoarthritis (moderate or severe )
* * ‫ﺗﻤﺰﻕ ﺍﻷﺭﺑﻄﺔ‬،‫ﺍﻟﺘﻬﺎﺏ ﺍﻟﻤﻔﺎﺻﻞ‬،‫ﺇﻧﺤﺮﺍﻑ ﺍﻟﻌﻤﻮﺩ ﺍﻟﻔﻘﺮﻱ‬,‫ﺍﻟﺪﻳﺴﻚ‬

Pregnant Female Only ‫ﻟﻸﻧﺜﻰ ﺍﻟﺤﺎﻣﻞ ﻓﻘﻂ‬

‫ﺣﻤﻞ ﺣﺎﻟﻲ ﺟﻨﻴﻦ ﻭﺍﺣﺪ‬
Current Single Pregnancy
* *
‫ﺣﻤﻞ ﺣﺎﻟﻲ ﻣﻊ ﻗﻴﺼﺮﻳﺔ ﺳﺎﺑﻘﺔ‬
Current Single Pregnancy with Previous CS Delivery
* *
‫ﺣﻤﻞ ﺣﺎﻟﻲ ﻣﺘﻌﺪﺩ ﺍﻷﺟﻨﺔ‬
Current Multiple Pregnancy
* *
Expected delivery date .. / .. / .... ‫ﺗﺎﺭﻳﺦ ﺍﻟﻮﻻﺩﺓ ﺍﻟﻤﺘﻮﻗﻊ‬
Employee and dependents details that need to be added ‫ﺑﻴﺎﻧﺎﺕ ﺍﻟﻤﻮﻇﻒ ﻭﺃﻓﺮﺍﺩ ﺍﻟﻌﺎﺋﻠﺔ ﺍﻟﻤﺮﺍﺩ ﺇﺿﺎﻓﺘﻬﻢ‬
In case of a yes answer above, please declare the case in the table below ‫ ﺍﻟﺮﺟﺎﺀ ﺫﻛﺮ ﺍﻟﺤﺎﻟﺔ ﻓﻲ ﺍﻟﺠﺪﻭﻝ ﺃﺩﻧﺎﻩ‬،‫ﻓﻲ ﺣﺎﻟﺔ ﺍﻹﺟﺎﺑﺔ ﺑﻨﻌﻢ ﺃﻋﻼﻩ‬
‫ﺇﺳﻢ ﻣﻘﺪﻡ ﺍﻟﺨﺪﻣﺔ‬ ‫ﺍﻟﺤﺎﻟﺔ‬ ‫ﺭﻗﻢ ﺍﻟﺠﻮﺍﻝ‬ ‫ﺍﻟﻄﻮﻝ‬ ‫ﺍﻟﻮﺯﻥ‬ ‫ﺭﻗﻢ ﺍﻟﻬﻮﻳﺔ‬ ‫ﺍﻟﻘﺮﺍﺑﺔ‬ ‫ﺍﻟﺠﻨﺲ‬ ‫ ﺃﻓﺮﺍﺩ ﺍﻟﻌﺎﺋﻠﺔ‬/ ‫ﺍﺳﻢ ﺍﻟﻤﻮﻇﻒ‬ ‫ﻡ‬
2016768679 Employee Male / ‫ ﺫﻛﺮ‬Abdullah Khaliqullah 1
2
3
4
5
Undertakings : ‫ﺍﻹﻗﺮﺍﺭ ﻭﺍﻟﺘﻔﻮﻳﺾ‬
1- I hereby undertake that all the above information is correct and the acceptance of my ‫ﻭﺍﻟﻤﻌﻠﻮﻣﺎﺕ ﺍﻟﻤﺬﻛﻮﺭﺓ ﺃﻋﻼﻩ ﻛﺎﻣﻠﺔ ﻭﺻﺤﻴﺤﺔ ﻭﺑﻨﺎﺀ ﻋﻠﻴﻪ ﻓﺈﻥ ﻗﺒﻮﻝ ﺍﻟﻄﻠﺐ ﺳﻴﺘﻢ‬: ‫ ﺃﻗﺮ ﺃﻥ ﺍﻟﺒﻴﺎﻧﺎﺕ‬-1
enrollment will be on the basis of such information and that Malath Cooperative Insurance ‫ﻋﻠﻰ ﺃﺳﺎﺱ ﻫﺬﻩ ﺍﻟﺒﻴﺎﻧﺎﺕ ﻭﺃﻥ ﺷﺮﻛﺔ ﻣﻼﺫ ﻟﻠﺘﺄﻣﻴﻦ ﺍﻟﺘﻌﺎﻭﻧﻲ ﻟﻬﺎ ﺍﻟﺤﻖ ﻓﻲ ﺍﻻﺗﺼﺎﻝ ﺑﺎﻟﻤﺴﺘﺸﻔﻴﺎﺕ ﺍﻟﺘﻲ‬
Company has the right to contact the hospital(s) I deal with to collect any ‫ﺃﺗﻌﺎﻣﻞ ﻣﻌﻬﺎ ﻟﺘﺰﻭﻳﺪﻫﺎ ﺑﺄﻱ ﻣﻌﻠﻮﻣﺎﺕ ﻃﺒﻴﺔ ﻗﺪ ﺗﺤﺘﺎﺝ ﺇﻟﻴﻬﺎ ﻟﺘﻘﻴﻴﻢ ﺍﻟﻤﺨﺎﻃﺮ‬
medical information needed to assess the risk(s).

2- I agree that Malath Cooperative Insurance Company has the right to reject the ‫ ﺃﻭﺍﻓﻖ ﻋﻠﻰ ﺃﺣﻘﻴﺔ ﺷﺮﻛﺔ ﻣﻼﺫ ﻟﻠﺘﺄﻣﻴﻦ ﻓﻲ ﺭﻓﺾ ﺍﻟﻤﻄﺎﻟﺒﺔ ﺃﻭ ﺍﻟﺘﻐﻄﻴﺔ ﻛﻠﻴﺎ ﻋﻨﺪ ﻋﺪﻡ ﺍﻹﻓﺼﺎﺡ ﻋﻦ ﻭﺟﻮﺩ ﺃﻱ ﻣﻦ ﺍﻟﺤﺎﻻﺕ‬-2
coverage/claims in full in case of no declaration of any cases prior to the contractual date or ‫ﺍﻟﻤﺬﻛﻮﺭﺓ ﺃﻋﻼﻩ ﺍﻟﺘﻲ ﻧﺸﺄﺕ ﻗﺒﻞ ﺗﺎﺭﻳﺦ ﺍﻟﺘﻌﺎﻗﺪ ﺃﻭ ﻗﺒﻞ ﺗﺴﺠﻴﻞ ﺃﻭ ﺇﺿﺎﻓﺔ ﻋﻀﻮ ﺧﻼﻝ ﻓﺘﺮﺓ ﺳﺮﻳﺎﻥ ﺍﻟﻌﻘﺪ‬
before enrolling or adding a new member during the contract.

3- I hereby confirm reading and understanding all points presented in this form and I agree that ‫ ﺃﻗﺮﺑﺄﻧﻲ ﻗﺪ ﻗﺮﺃﺕ ﻭﻓﻬﻤﺖ ﺟﻤﻴﻊ ﻣﺎ ﺟﺎﺀ ﻓﻲ ﻫﺬﺍ ﺍﻟﻨﻤﻮﺫﺝ ﻛﻤﺎ ﺃﺗﻌﻬﺪ ﺑﺄﻥ ﻋﺪﻡ ﺇﺷﺎﺭﺗﻲ ﺃﻣﺎﻡ ﺃﻱ ﻣﻦ‬-3
not marking any case is understood as “Nothing requires declaration” and I sign on these ‫ﺍﻟﺤﺎﻻﺕ ﺍﻟﻤﺬﻛﻮﺭﺓ ﺃﻋﻼﻩ ﻳﻌﺘﺒﺮ ﺑﻤﺜﺎﺑﺔ ﻧﻔﻲ ﻭﺟﻮﺩ ﻣﺎﻳﺴﺘﺤﻖ ﺍﻹﻓﺼﺎﺡ ﻋﻨﻪ ﻭﻋﻠﻴﻪ ﺃﻭﻗﻊ‬
basis.
4- Failure to fill the weight and height information will result in refusal to cover
the cost of obesity surgery. ‫ ﻋﺪﻡ ﺗﻌﺒﺌﺔ ﺑﻴﺎﻧﺎﺕ ﺍﻟﻄﻮﻝ ﻭﺍﻟﻮﺯﻥ ﺳﻴﺆﺩﻱ ﺇﻟﻰ ﺭﻓﺾ ﺗﻐﻄﻴﺔ ﺗﻜﺎﻟﻴﻒ ﻋﻤﻠﻴﺔ ﺟﺮﺍﺣﺔ ﺍﻟﺴﻤﻨﺔ ﺍﻟﻤﻔﺮﻃﺔ‬-4

Entity's stamp ‫ﺧﺘﻢ ﺟﻬﺔ ﺍﻟﻌﻤﻞ‬ Insured Signature ‫ﺗﻮﻗﻴﻊ ﺍﻟﻤﻮﻇﻒ‬ Date ‫ﺍﻟﺘﺎﺭﻳﺦ‬
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New_Health_Insurance.rdf Page 21 of 39 V.20 13-DEC-2023 01:30 PM

 ‫ﻧﻤﻮﺫﺝ ﺍﻻﻓﺼﺎﺡ ﺍﻟﻄﺒﻲ ﺍﻟﻤﻮﺣﺪ‬
Unified Medical Declaration Form
Product Code: A-MLTH-2-C-08-014
Dear Insured: ‫ﻋﺰﻳﺰﻱ ﺍﻟﻤﺆﻣﻦ ﻟﻪ‬
Please Fill out the form correctly for the purpose of pricing and to ensured that you and your ‫ﻧﺄﻣﻞ ﻗﻴﺎﻣﻚ ﺑﺘﻌﺒﺌﺔ ﻫﺬﺍ ﺍﻟﻨﻤﻮﺫﺝ ﺑﺎﻟﺸﻜﻞ ﺍﻟﺼﺤﻴﺢ ﻟﻐﺮﺽ ﺍﻟﺘﺴﻌﻴﺮ ﻭﻟﻀﻤﺎﻥ ﺣﺼﻮﻟﻚ ﻭﺃﻓﺮﺍﺩ ﺃﺳﺮﺗﻚ ﻋﻠﻰ ﺧﺪﻣﺎﺕ‬
family receive health care services as required according to your unfied policy benefit ‫ﺍﻟﺮﻋﺎﻳﺔ ﺍﻟﺼﺤﻴﺔ ﺑﺎﻟﺸﻜﻞ ﺍﻟﻤﻄﻠﻮﺏ ﺣﺴﺐ ﻣﻨﺎﻓﻊ ﺍﻟﻮﺛﻴﻘﺔ ﺍﻟﻤﻮﺣﺪﺓ‬

Addition ‫ﺇﺿﺎﻓﺔ‬ New ‫ﺟﺪﻳﺪ‬ Type ‫ﻧﻮﻉ ﺍﻟﻄﻠﺐ‬

CR No 7011507360 ‫ﺍﻟﺴﺠﻞ ﺍﻟﺘﺠﺎﺭﻱ‬ Entity Name HADDAJ AL HIJAZ EST ‫ﺃﺳﻢ ﺍﻟﻤﻨﺸﺄﺓ‬
Mobile No 0507938193 ‫ﺭﻗﻢ ﺍﻟﺠﻮﺍﻝ‬ Naila Ashfaq Ahmed Chowdhary ‫ﺍﺳﻢ ﺍﻟﻤﻮﻇﻒ‬
ID Number 2 3 5 3 9 9 2 9 9 9 ‫ﺭﻗﻢ ﺍﻟﻬﻮﻳﺔ‬
Gender Female / ‫ﺍﻟﺠﻨﺲ ﺃﻧﺜﻰ‬ Nationality India ‫ ﺍﻟﺠﻨﺴﻴﺔ‬Marital status Married R ‫ﻣﺘﺰﻭﺝ‬ Single * ‫ﺃﻋﺰﺏ‬ ‫ﺍﻟﺤﺎﻟﺔ ﺍﻻﺟﺘﻤﺎﻋﻴﺔ‬
Please declare any of the below cases by marking P under the word Yes ‫ ﻓﻲ ﺍﻟﻤﺮﺑﻊ ﺗﺤﺖ ﻛﻠﻤﺔ ﻧﻌﻢ‬P ‫ﻳﺮﺟﻰ ﺍﻹﻓﺼﺎﺡ ﻋﻦ ﻭﺟﻮﺩ ﺃﻱ ﻣﻦ ﺍﻟﺤﺎﻻﺕ ﺍﺩﻧﺎﻩ ﺑﻮﺿﻊ ﺇﺷﺎﺭﺓ‬
"Below Undeclared Medical Case May Not Be Covered" No / ‫ﻻ‬ Yes / ‫ﻧﻌـﻢ‬ "‫"ﻟﻦ ﺗﺘﻢ ﺍﻟﺘﻐﻄﻴﺔ ﺍﻟﺘﺄﻣﻴﻨﻴﺔ ﻟﻠﺤﺎﻻﺕ ﺃﺩﻧﺎﻩ ﻓﻰ ﺣﺎﻝ ﻋﺪﻡ ﺍﻹﻓﺼﺎﺡ ﻋﻨﻬﺎ‬
Any hospital admission during last 12 months. ‫ ﺷﻬﺮ‬12 ‫ﻫﻞ ﺗﻢ ﺍﻟﺘﻨﻮﻳﻢ ﺑﺎﻟﻤﺴﺘﺸﻔﻰ ﺧﻼﻝ ﺃﺧﺮ‬
"Admission: registering as an admitted patient at the hospital until the following morning "
* * " ‫ ﺗﺴﺠﻴﻞ ﺍﻟﺸﺨﺺ ﺍﻟﻤﺆﻣﻦ ﻟﻪ ﻛﻤﺮﻳﺾ ﻣﻨﻮﻡ ﻓﻲ ﺍﻟﻤﺴﺘﺸﻔﻰ ﺣﺘﻰ ﺻﺒﺎﺡ ﺍﻟﻴﻮﻡ ﺍﻟﺘﺎﻟﻲ‬: ‫" ﺍﻟﺘﻨﻮﻳﻢ‬

Have you been diagnosed with any of the following chronic disease limited ‫ﻫﻞ ﺗﻢ ﺗﺸﺨﻴﺼﻚ ﺑﺄﻯ ﻣﻦ ﺍﻷﻣﺮﺍﺽ ﺍﻟﺘﺎﻟﻴﺔ ﻓﻘﻂ‬
to:Autism, listed Benign Tumor (Breast tumors, fibroid uterus, benign prostatic hyperplasia, ‫ﺃﻭﺭﺍﻡ ﺃﻭ‬,‫ﺗﻀﺨﻢ ﺍﻟﺒﺮﻭﺳﺘﺎﺗﺎ ﺍﻟﺤﻤﻴﺪ‬,‫ ﺃﻭﺭﺍﻡ ﺍﻟﺮﺣﻢ ﺍﻟﻠﻴﻔﻰ‬, ‫ﺍﻻﻭﺭﺍﻡ ﺍﻟﺤﻤﻴﺪﺓ ﺍﻟﺘﺎﻟﻴﺔ )ﺃﻭﺭﺍﻡ ﺍﻟﺜﺪﻯ‬,‫ﺍﻷﻭﺭﺍﻡ ﺍﻟﺴﺮﻃﺎﻧﻴﺔ‬,‫ﺍﻟﺘﻮﺣﺪ‬
thyroid goiter and parathyroid glands, live tumors, colon tumors). Malignant tumors, listed ‫ﺃﻣﺮﺍﺽ ﺍﻟﻘﻠﺐ ﺍﻟﺘﺎﻟﻴﺔ)ﺃﻣﺮﺍﺽ ﺷﺮﺍﻳﻴﻦ ﻭﺻﻤﺎﻣﺎﺕ ﺗﻀﺨﻢ ﺍﻟﻐﺪﺓ ﺍﻟﺪﺭﻗﻴﺔ‬, (‫ﺃﻭﺭﺍﻡ ﺍﻟﻘﻮﻟﻮﻥ‬, ‫ﻭﺃﻭﺭﺍﻡ ﺍﻻﻟﻜﺒﺪ‬,‫ﻭ ﺍﻟﺠﺎﺭ ﺍﻟﺪﺭﻗﻴﺔ‬
Cardiac diseases coronary and valve heart diseases, heart failure, cardiac fibrillation
myocardial infraction, heart clots). Chronic Hepatitis C. Gallstones Sever Kidney failure (stage
* * ‫ﺍﻻﻟﺘﻬﺎﺏ ﺍﻟﻜﺒﺪﻯ ﺍﻟﻔﻴﺮﻭﺳﻰ ﺍﻟﻤﺰﻣﻦ‬.( ‫ﺍﻟﺮﺟﻔﺎﻥ ﺍﻟﻘﻠﺒﻰ ﻭﺟﻠﻄﺎﺕ ﺍﻟﻘﻠﺐ‬, ‫ﻓﺸﻞ ﻋﻀﻠﺔ ﺍﻟﻘﻠﺐ‬, ‫ﺣﺼﻮﺍﺕ ﺍﻟﻤﺮﺍﺭﺓ ﺍﻟﻘﻠﺐ‬, ‫ﺝ ﻭﺳﻰ‬
,‫ ﺍﻟﺘﺮﺷﻴﺢ ﺍﻟﻜﻠﻮﻯ ﺃﻗﻞ ﻣﻦ‬,‫ ﺍﻟﻔﺸﻞ ﺍﻟﻜﻠﻮﻯﺍﻟﺸﺪﻳﺪ )ﺍﻟﻤﺮﺣﻠﺔ ﺍﻟﺨﺎﻣﺴﺔ ﻣﻦ ﺍﻣﺮﺍﺽ ﺍﻟﻜﻠﻰ ﺍﻟﺘﻰ ﺗﺴﺘﺪﻋﻰ ﺍﻟﻐﺴﻴﻞ ﺍﻟﻜﻠﻮﻯ‬15
5 Requiring dialysis, clearance of less tha 15 ml/ minute*). Urinary tract ‫ﻣﺮﺽ‬, ‫ﺩﻗﻴﻘﺔ(ﺣﺼﻮﺍﺕ ﺍﻟﻤﺴﺎﻟﻚ ﺍﻟﺒﻮﻟﻴﺔﺃﻣﺮﺍﺽ ﺍﻟﻤﻨﺎﻋﺔ ﺍﻟﺘﺎﻟﻴﺔ )ﺍﻟﺬﺋﺒﺔ ﺍﻟﺤﻤﺮﺍﺀﻭﺍﻟﺘﻬﺎﺏ ﺍﻟﻤﻔﺎﺻﻞ ﺍﻟﺮﻭﻣﺎﺗﻴﺰﻣﻴﺔﻭ ﺍﻟﺼﺪﻓﻴﺔ‬/‫ﻣﻞ‬
stones, hernias. Autoimmune disease (lupus, rheumatoid arthritis, psoriasis, Crohn's disease, ‫ﺍﻟﺘﻬﺎﺏ ﺍﻟﻘﻮﻟﻮﻥ ﺍﻟﺘﻘﺮﺣﻰ‬, ‫ﻛﺮﻭﻧﺰ‬,
ulcerative colitis,multiple sclerosis, celiac disease) ‫ﺣﺴﺎﺳﻴﺔ ﺍﻟﻘﻤﺢ‬, ‫ﺍﻟﺘﺼﻠﺐ ﺍﻟﻠﻮﻳﺤﻰ‬

Have you been diagnosed with any of the following congenital disorder or
hereditary diseases limited to: Cerebral palsy, Sickle cell disorder, Thalassemia, ‫ﻫﻞ ﺗﻢ ﺗﺸﺨﻴﺼﻚ ﺑﺄﻱ ﻣﻦ ﺍﻷﻣﺮﺍﺽ ﺍﻟﻮﺭﺍﺛﻴﺔ ﺃﻭ ﺍﻟﺘﺸﻮﻫﺎﺕ ﺍﻟﺨﻠﻘﻴﺔ ﺍﻟﺘﺎﻟﻴﺔ ﻓﻘﻂ‬
hemophilia, metabolic diseases, Hydrocephalus, spinal muscle atrophy, genital ‫ ﺿﻤﻮﺭ‬،‫ ﺃﺳﺘﺴﻘﺎﺀ ﺍﻟﺮﺃﺱ‬،‫ ﺃﻣﺮﺍﺽ ﺍﻟﺘﻤﺜﻴﻞ ﺍﻟﻐﺬﺍﺋﻲ‬،‫ ﺍﻟﻬﻴﻤﻮﻓﻴﻠﻴﺎ‬،‫ ﺍﻟﺘﻼﺳﻴﻤﻴﺎ‬،‫ﺍﺿﻄﺮﺍﺏ ﺍﻟﺨﻼﻳﺎ ﺍﻟﻤﻨﺠﻠﻴﺔ‬, ‫ﺍﻟﺸﻠﻞ ﺍﻟﺪﻣﺎﻏﻰ‬
malformations, chromosomal abnormalities. Gaucher's disease, G6PD Deficiency, cystic
fibrosis, hemochromatosis, Wilson disease. Polycystic Kidney Disease.
* * ‫ ﻣﺮﺽ ﺍﻟﺘﻜﺴﺮﺍﻟﻔﻮﻟﻰ‬،‫ ﻣﺮﺽ ﻏﻮﺷﺮ‬،‫ ﺃﻣﺮﺍﺽ ﺍﻟﻜﺮﻭﻣﻮﺳﻮﻣﺎﺕ‬،‫ ﺗﺸﻮﻫﺎﺕ ﺍﻷﻋﻀﺎﺀ ﺍﻟﺘﻨﺎﺳﻠﻴﺔ‬،‫ﺍﻟﻌﻀﻼﺕ ﺍﻟﺸﻮﻛﻲ‬
‫ﺗﻜﻴﺲ‬,‫ﻣﺮﺽ ﻭﻳﻠﺴﻮﻥ‬, (‫ ﻣﺮﺽ ﺗﻜﺪﺱ ﺍﻟﺤﺪﻳﺪ )ﻫﻴﻤﻮﻛﺮﻭﻣﺎﺗﻮﺳﻴﺲ‬،‫( ﺍﻟﺘﻠﻴﻒ ﺍﻟﻜﻴﺴﻲ ﻟﻠﺮﺋﺔ‬G6PD)
‫ﺍﻟﻜﻠﻴﺘﻴﻦ ﺍﻟﺨﻠﻔﻰ ﺍﻟﻮﺭﺍﺋﻰ‬

Have you been diagnosed with any of following eye diseases limited to: ،‫ ﻣﻴﺎﺓ ﺯﺭﻗﺎﺀ‬،‫ ﻣﻴﺎﺓ ﺑﻴﻀﺎﺀ‬:‫ﻫﻞ ﺗﻢ ﺗﺸﺨﻴﺼﻚ ﺑﺄﻱ ﻣﻦ ﺃﻣﺮﺍﺽ ﺍﻟﻌﻴﻦ ﺍﻟﺘﺎﻟﻴﺔ ﻓﻘﻂ‬
Cataract, Glaucoma, Retinal diseases. * * ‫ﺃﻣﺮﺍﺽ ﺍﻟﺸﺒﻜﻴﺔ‬
Have you been diagnosed with any of the following bone diseases limited ‫ ﺍﻹﻧﺰﻻﻕ ﺍﻟﻐﻀﺮﻭﻓﻲ‬:‫ﻫﻞ ﺗﻢ ﺗﺸﺨﻴﺼﻚ ﺑﺄﻱ ﻣﻦ ﺃﻣﺮﺍﺽ ﺍﻟﻌﻈﺎﻡ ﺍﻟﺘﺎﻟﻴﺔ ﻓﻘﻂ‬
to:Vertebral disc prolapse (moderate or severe), Scoliosis (moderate or severe)**, or ligament
tears, osteoarthritis (moderate or severe )
* * ‫ﺗﻤﺰﻕ ﺍﻷﺭﺑﻄﺔ‬،‫ﺍﻟﺘﻬﺎﺏ ﺍﻟﻤﻔﺎﺻﻞ‬،‫ﺇﻧﺤﺮﺍﻑ ﺍﻟﻌﻤﻮﺩ ﺍﻟﻔﻘﺮﻱ‬,‫ﺍﻟﺪﻳﺴﻚ‬

Pregnant Female Only ‫ﻟﻸﻧﺜﻰ ﺍﻟﺤﺎﻣﻞ ﻓﻘﻂ‬

‫ﺣﻤﻞ ﺣﺎﻟﻲ ﺟﻨﻴﻦ ﻭﺍﺣﺪ‬
Current Single Pregnancy
* *
‫ﺣﻤﻞ ﺣﺎﻟﻲ ﻣﻊ ﻗﻴﺼﺮﻳﺔ ﺳﺎﺑﻘﺔ‬
Current Single Pregnancy with Previous CS Delivery
* *
‫ﺣﻤﻞ ﺣﺎﻟﻲ ﻣﺘﻌﺪﺩ ﺍﻷﺟﻨﺔ‬
Current Multiple Pregnancy
* *
Expected delivery date .. / .. / .... ‫ﺗﺎﺭﻳﺦ ﺍﻟﻮﻻﺩﺓ ﺍﻟﻤﺘﻮﻗﻊ‬
Employee and dependents details that need to be added ‫ﺑﻴﺎﻧﺎﺕ ﺍﻟﻤﻮﻇﻒ ﻭﺃﻓﺮﺍﺩ ﺍﻟﻌﺎﺋﻠﺔ ﺍﻟﻤﺮﺍﺩ ﺇﺿﺎﻓﺘﻬﻢ‬
In case of a yes answer above, please declare the case in the table below ‫ ﺍﻟﺮﺟﺎﺀ ﺫﻛﺮ ﺍﻟﺤﺎﻟﺔ ﻓﻲ ﺍﻟﺠﺪﻭﻝ ﺃﺩﻧﺎﻩ‬،‫ﻓﻲ ﺣﺎﻟﺔ ﺍﻹﺟﺎﺑﺔ ﺑﻨﻌﻢ ﺃﻋﻼﻩ‬
‫ﺇﺳﻢ ﻣﻘﺪﻡ ﺍﻟﺨﺪﻣﺔ‬ ‫ﺍﻟﺤﺎﻟﺔ‬ ‫ﺭﻗﻢ ﺍﻟﺠﻮﺍﻝ‬ ‫ﺍﻟﻄﻮﻝ‬ ‫ﺍﻟﻮﺯﻥ‬ ‫ﺭﻗﻢ ﺍﻟﻬﻮﻳﺔ‬ ‫ﺍﻟﻘﺮﺍﺑﺔ‬ ‫ﺍﻟﺠﻨﺲ‬ ‫ ﺃﻓﺮﺍﺩ ﺍﻟﻌﺎﺋﻠﺔ‬/ ‫ﺍﺳﻢ ﺍﻟﻤﻮﻇﻒ‬ ‫ﻡ‬
2353992999 Spouse Female / ‫ ﺃﻧﺜﻰ‬Naila Ashfaq Ahmed Chowdha 1
2
3
4
5
Undertakings : ‫ﺍﻹﻗﺮﺍﺭ ﻭﺍﻟﺘﻔﻮﻳﺾ‬
1- I hereby undertake that all the above information is correct and the acceptance of my ‫ﻭﺍﻟﻤﻌﻠﻮﻣﺎﺕ ﺍﻟﻤﺬﻛﻮﺭﺓ ﺃﻋﻼﻩ ﻛﺎﻣﻠﺔ ﻭﺻﺤﻴﺤﺔ ﻭﺑﻨﺎﺀ ﻋﻠﻴﻪ ﻓﺈﻥ ﻗﺒﻮﻝ ﺍﻟﻄﻠﺐ ﺳﻴﺘﻢ‬: ‫ ﺃﻗﺮ ﺃﻥ ﺍﻟﺒﻴﺎﻧﺎﺕ‬-1
enrollment will be on the basis of such information and that Malath Cooperative Insurance ‫ﻋﻠﻰ ﺃﺳﺎﺱ ﻫﺬﻩ ﺍﻟﺒﻴﺎﻧﺎﺕ ﻭﺃﻥ ﺷﺮﻛﺔ ﻣﻼﺫ ﻟﻠﺘﺄﻣﻴﻦ ﺍﻟﺘﻌﺎﻭﻧﻲ ﻟﻬﺎ ﺍﻟﺤﻖ ﻓﻲ ﺍﻻﺗﺼﺎﻝ ﺑﺎﻟﻤﺴﺘﺸﻔﻴﺎﺕ ﺍﻟﺘﻲ‬
Company has the right to contact the hospital(s) I deal with to collect any ‫ﺃﺗﻌﺎﻣﻞ ﻣﻌﻬﺎ ﻟﺘﺰﻭﻳﺪﻫﺎ ﺑﺄﻱ ﻣﻌﻠﻮﻣﺎﺕ ﻃﺒﻴﺔ ﻗﺪ ﺗﺤﺘﺎﺝ ﺇﻟﻴﻬﺎ ﻟﺘﻘﻴﻴﻢ ﺍﻟﻤﺨﺎﻃﺮ‬
medical information needed to assess the risk(s).

2- I agree that Malath Cooperative Insurance Company has the right to reject the ‫ ﺃﻭﺍﻓﻖ ﻋﻠﻰ ﺃﺣﻘﻴﺔ ﺷﺮﻛﺔ ﻣﻼﺫ ﻟﻠﺘﺄﻣﻴﻦ ﻓﻲ ﺭﻓﺾ ﺍﻟﻤﻄﺎﻟﺒﺔ ﺃﻭ ﺍﻟﺘﻐﻄﻴﺔ ﻛﻠﻴﺎ ﻋﻨﺪ ﻋﺪﻡ ﺍﻹﻓﺼﺎﺡ ﻋﻦ ﻭﺟﻮﺩ ﺃﻱ ﻣﻦ ﺍﻟﺤﺎﻻﺕ‬-2
coverage/claims in full in case of no declaration of any cases prior to the contractual date or ‫ﺍﻟﻤﺬﻛﻮﺭﺓ ﺃﻋﻼﻩ ﺍﻟﺘﻲ ﻧﺸﺄﺕ ﻗﺒﻞ ﺗﺎﺭﻳﺦ ﺍﻟﺘﻌﺎﻗﺪ ﺃﻭ ﻗﺒﻞ ﺗﺴﺠﻴﻞ ﺃﻭ ﺇﺿﺎﻓﺔ ﻋﻀﻮ ﺧﻼﻝ ﻓﺘﺮﺓ ﺳﺮﻳﺎﻥ ﺍﻟﻌﻘﺪ‬
before enrolling or adding a new member during the contract.

3- I hereby confirm reading and understanding all points presented in this form and I agree that ‫ ﺃﻗﺮﺑﺄﻧﻲ ﻗﺪ ﻗﺮﺃﺕ ﻭﻓﻬﻤﺖ ﺟﻤﻴﻊ ﻣﺎ ﺟﺎﺀ ﻓﻲ ﻫﺬﺍ ﺍﻟﻨﻤﻮﺫﺝ ﻛﻤﺎ ﺃﺗﻌﻬﺪ ﺑﺄﻥ ﻋﺪﻡ ﺇﺷﺎﺭﺗﻲ ﺃﻣﺎﻡ ﺃﻱ ﻣﻦ‬-3
not marking any case is understood as “Nothing requires declaration” and I sign on these ‫ﺍﻟﺤﺎﻻﺕ ﺍﻟﻤﺬﻛﻮﺭﺓ ﺃﻋﻼﻩ ﻳﻌﺘﺒﺮ ﺑﻤﺜﺎﺑﺔ ﻧﻔﻲ ﻭﺟﻮﺩ ﻣﺎﻳﺴﺘﺤﻖ ﺍﻹﻓﺼﺎﺡ ﻋﻨﻪ ﻭﻋﻠﻴﻪ ﺃﻭﻗﻊ‬
basis.
4- Failure to fill the weight and height information will result in refusal to cover
the cost of obesity surgery. ‫ ﻋﺪﻡ ﺗﻌﺒﺌﺔ ﺑﻴﺎﻧﺎﺕ ﺍﻟﻄﻮﻝ ﻭﺍﻟﻮﺯﻥ ﺳﻴﺆﺩﻱ ﺇﻟﻰ ﺭﻓﺾ ﺗﻐﻄﻴﺔ ﺗﻜﺎﻟﻴﻒ ﻋﻤﻠﻴﺔ ﺟﺮﺍﺣﺔ ﺍﻟﺴﻤﻨﺔ ﺍﻟﻤﻔﺮﻃﺔ‬-4

Entity's stamp ‫ﺧﺘﻢ ﺟﻬﺔ ﺍﻟﻌﻤﻞ‬ Insured Signature ‫ﺗﻮﻗﻴﻊ ﺍﻟﻤﻮﻇﻒ‬ Date ‫ﺍﻟﺘﺎﺭﻳﺦ‬
.. / .. / ....

New_Health_Insurance.rdf Page 22 of 39 V.20 13-DEC-2023 01:30 PM

 ‫ﻧﻤﻮﺫﺝ ﺍﻻﻓﺼﺎﺡ ﺍﻟﻄﺒﻲ ﺍﻟﻤﻮﺣﺪ‬
Unified Medical Declaration Form
Product Code: A-MLTH-2-C-08-014
Dear Insured: ‫ﻋﺰﻳﺰﻱ ﺍﻟﻤﺆﻣﻦ ﻟﻪ‬
Please Fill out the form correctly for the purpose of pricing and to ensured that you and your ‫ﻧﺄﻣﻞ ﻗﻴﺎﻣﻚ ﺑﺘﻌﺒﺌﺔ ﻫﺬﺍ ﺍﻟﻨﻤﻮﺫﺝ ﺑﺎﻟﺸﻜﻞ ﺍﻟﺼﺤﻴﺢ ﻟﻐﺮﺽ ﺍﻟﺘﺴﻌﻴﺮ ﻭﻟﻀﻤﺎﻥ ﺣﺼﻮﻟﻚ ﻭﺃﻓﺮﺍﺩ ﺃﺳﺮﺗﻚ ﻋﻠﻰ ﺧﺪﻣﺎﺕ‬
family receive health care services as required according to your unfied policy benefit ‫ﺍﻟﺮﻋﺎﻳﺔ ﺍﻟﺼﺤﻴﺔ ﺑﺎﻟﺸﻜﻞ ﺍﻟﻤﻄﻠﻮﺏ ﺣﺴﺐ ﻣﻨﺎﻓﻊ ﺍﻟﻮﺛﻴﻘﺔ ﺍﻟﻤﻮﺣﺪﺓ‬

Addition ‫ﺇﺿﺎﻓﺔ‬ New ‫ﺟﺪﻳﺪ‬ Type ‫ﻧﻮﻉ ﺍﻟﻄﻠﺐ‬

CR No 7011507360 ‫ﺍﻟﺴﺠﻞ ﺍﻟﺘﺠﺎﺭﻱ‬ Entity Name HADDAJ AL HIJAZ EST ‫ﺃﺳﻢ ﺍﻟﻤﻨﺸﺄﺓ‬
Mobile No 0544451736 ‫ﺭﻗﻢ ﺍﻟﺠﻮﺍﻝ‬ Mohammed Abdullah Khaliqullah ‫ﺍﺳﻢ ﺍﻟﻤﻮﻇﻒ‬
ID Number 2 3 7 5 1 5 4 3 6 2 ‫ﺭﻗﻢ ﺍﻟﻬﻮﻳﺔ‬
Male / ‫ﺫﻛﺮ‬ India
Gender ‫ ﺍﻟﺠﻨﺲ‬Nationality ‫ ﺍﻟﺠﻨﺴﻴﺔ‬Marital status Married * ‫ﻣﺘﺰﻭﺝ‬ Single R ‫ﺃﻋﺰﺏ‬ ‫ﺍﻟﺤﺎﻟﺔ ﺍﻻﺟﺘﻤﺎﻋﻴﺔ‬
Please declare any of the below cases by marking P under the word Yes ‫ ﻓﻲ ﺍﻟﻤﺮﺑﻊ ﺗﺤﺖ ﻛﻠﻤﺔ ﻧﻌﻢ‬P ‫ﻳﺮﺟﻰ ﺍﻹﻓﺼﺎﺡ ﻋﻦ ﻭﺟﻮﺩ ﺃﻱ ﻣﻦ ﺍﻟﺤﺎﻻﺕ ﺍﺩﻧﺎﻩ ﺑﻮﺿﻊ ﺇﺷﺎﺭﺓ‬
"Below Undeclared Medical Case May Not Be Covered" No / ‫ﻻ‬ Yes / ‫ﻧﻌـﻢ‬ "‫"ﻟﻦ ﺗﺘﻢ ﺍﻟﺘﻐﻄﻴﺔ ﺍﻟﺘﺄﻣﻴﻨﻴﺔ ﻟﻠﺤﺎﻻﺕ ﺃﺩﻧﺎﻩ ﻓﻰ ﺣﺎﻝ ﻋﺪﻡ ﺍﻹﻓﺼﺎﺡ ﻋﻨﻬﺎ‬
Any hospital admission during last 12 months. ‫ ﺷﻬﺮ‬12 ‫ﻫﻞ ﺗﻢ ﺍﻟﺘﻨﻮﻳﻢ ﺑﺎﻟﻤﺴﺘﺸﻔﻰ ﺧﻼﻝ ﺃﺧﺮ‬
"Admission: registering as an admitted patient at the hospital until the following morning "
* * " ‫ ﺗﺴﺠﻴﻞ ﺍﻟﺸﺨﺺ ﺍﻟﻤﺆﻣﻦ ﻟﻪ ﻛﻤﺮﻳﺾ ﻣﻨﻮﻡ ﻓﻲ ﺍﻟﻤﺴﺘﺸﻔﻰ ﺣﺘﻰ ﺻﺒﺎﺡ ﺍﻟﻴﻮﻡ ﺍﻟﺘﺎﻟﻲ‬: ‫" ﺍﻟﺘﻨﻮﻳﻢ‬

Have you been diagnosed with any of the following chronic disease limited ‫ﻫﻞ ﺗﻢ ﺗﺸﺨﻴﺼﻚ ﺑﺄﻯ ﻣﻦ ﺍﻷﻣﺮﺍﺽ ﺍﻟﺘﺎﻟﻴﺔ ﻓﻘﻂ‬
to:Autism, listed Benign Tumor (Breast tumors, fibroid uterus, benign prostatic hyperplasia, ‫ﺃﻭﺭﺍﻡ ﺃﻭ‬,‫ﺗﻀﺨﻢ ﺍﻟﺒﺮﻭﺳﺘﺎﺗﺎ ﺍﻟﺤﻤﻴﺪ‬,‫ ﺃﻭﺭﺍﻡ ﺍﻟﺮﺣﻢ ﺍﻟﻠﻴﻔﻰ‬, ‫ﺍﻻﻭﺭﺍﻡ ﺍﻟﺤﻤﻴﺪﺓ ﺍﻟﺘﺎﻟﻴﺔ )ﺃﻭﺭﺍﻡ ﺍﻟﺜﺪﻯ‬,‫ﺍﻷﻭﺭﺍﻡ ﺍﻟﺴﺮﻃﺎﻧﻴﺔ‬,‫ﺍﻟﺘﻮﺣﺪ‬
thyroid goiter and parathyroid glands, live tumors, colon tumors). Malignant tumors, listed ‫ﺃﻣﺮﺍﺽ ﺍﻟﻘﻠﺐ ﺍﻟﺘﺎﻟﻴﺔ)ﺃﻣﺮﺍﺽ ﺷﺮﺍﻳﻴﻦ ﻭﺻﻤﺎﻣﺎﺕ ﺗﻀﺨﻢ ﺍﻟﻐﺪﺓ ﺍﻟﺪﺭﻗﻴﺔ‬, (‫ﺃﻭﺭﺍﻡ ﺍﻟﻘﻮﻟﻮﻥ‬, ‫ﻭﺃﻭﺭﺍﻡ ﺍﻻﻟﻜﺒﺪ‬,‫ﻭ ﺍﻟﺠﺎﺭ ﺍﻟﺪﺭﻗﻴﺔ‬
Cardiac diseases coronary and valve heart diseases, heart failure, cardiac fibrillation
myocardial infraction, heart clots). Chronic Hepatitis C. Gallstones Sever Kidney failure (stage
* * ‫ﺍﻻﻟﺘﻬﺎﺏ ﺍﻟﻜﺒﺪﻯ ﺍﻟﻔﻴﺮﻭﺳﻰ ﺍﻟﻤﺰﻣﻦ‬.( ‫ﺍﻟﺮﺟﻔﺎﻥ ﺍﻟﻘﻠﺒﻰ ﻭﺟﻠﻄﺎﺕ ﺍﻟﻘﻠﺐ‬, ‫ﻓﺸﻞ ﻋﻀﻠﺔ ﺍﻟﻘﻠﺐ‬, ‫ﺣﺼﻮﺍﺕ ﺍﻟﻤﺮﺍﺭﺓ ﺍﻟﻘﻠﺐ‬, ‫ﺝ ﻭﺳﻰ‬
,‫ ﺍﻟﺘﺮﺷﻴﺢ ﺍﻟﻜﻠﻮﻯ ﺃﻗﻞ ﻣﻦ‬,‫ ﺍﻟﻔﺸﻞ ﺍﻟﻜﻠﻮﻯﺍﻟﺸﺪﻳﺪ )ﺍﻟﻤﺮﺣﻠﺔ ﺍﻟﺨﺎﻣﺴﺔ ﻣﻦ ﺍﻣﺮﺍﺽ ﺍﻟﻜﻠﻰ ﺍﻟﺘﻰ ﺗﺴﺘﺪﻋﻰ ﺍﻟﻐﺴﻴﻞ ﺍﻟﻜﻠﻮﻯ‬15
5 Requiring dialysis, clearance of less tha 15 ml/ minute*). Urinary tract ‫ﻣﺮﺽ‬, ‫ﺩﻗﻴﻘﺔ(ﺣﺼﻮﺍﺕ ﺍﻟﻤﺴﺎﻟﻚ ﺍﻟﺒﻮﻟﻴﺔﺃﻣﺮﺍﺽ ﺍﻟﻤﻨﺎﻋﺔ ﺍﻟﺘﺎﻟﻴﺔ )ﺍﻟﺬﺋﺒﺔ ﺍﻟﺤﻤﺮﺍﺀﻭﺍﻟﺘﻬﺎﺏ ﺍﻟﻤﻔﺎﺻﻞ ﺍﻟﺮﻭﻣﺎﺗﻴﺰﻣﻴﺔﻭ ﺍﻟﺼﺪﻓﻴﺔ‬/‫ﻣﻞ‬
stones, hernias. Autoimmune disease (lupus, rheumatoid arthritis, psoriasis, Crohn's disease, ‫ﺍﻟﺘﻬﺎﺏ ﺍﻟﻘﻮﻟﻮﻥ ﺍﻟﺘﻘﺮﺣﻰ‬, ‫ﻛﺮﻭﻧﺰ‬,
ulcerative colitis,multiple sclerosis, celiac disease) ‫ﺣﺴﺎﺳﻴﺔ ﺍﻟﻘﻤﺢ‬, ‫ﺍﻟﺘﺼﻠﺐ ﺍﻟﻠﻮﻳﺤﻰ‬

Have you been diagnosed with any of the following congenital disorder or
hereditary diseases limited to: Cerebral palsy, Sickle cell disorder, Thalassemia, ‫ﻫﻞ ﺗﻢ ﺗﺸﺨﻴﺼﻚ ﺑﺄﻱ ﻣﻦ ﺍﻷﻣﺮﺍﺽ ﺍﻟﻮﺭﺍﺛﻴﺔ ﺃﻭ ﺍﻟﺘﺸﻮﻫﺎﺕ ﺍﻟﺨﻠﻘﻴﺔ ﺍﻟﺘﺎﻟﻴﺔ ﻓﻘﻂ‬
hemophilia, metabolic diseases, Hydrocephalus, spinal muscle atrophy, genital ‫ ﺿﻤﻮﺭ‬،‫ ﺃﺳﺘﺴﻘﺎﺀ ﺍﻟﺮﺃﺱ‬،‫ ﺃﻣﺮﺍﺽ ﺍﻟﺘﻤﺜﻴﻞ ﺍﻟﻐﺬﺍﺋﻲ‬،‫ ﺍﻟﻬﻴﻤﻮﻓﻴﻠﻴﺎ‬،‫ ﺍﻟﺘﻼﺳﻴﻤﻴﺎ‬،‫ﺍﺿﻄﺮﺍﺏ ﺍﻟﺨﻼﻳﺎ ﺍﻟﻤﻨﺠﻠﻴﺔ‬, ‫ﺍﻟﺸﻠﻞ ﺍﻟﺪﻣﺎﻏﻰ‬
malformations, chromosomal abnormalities. Gaucher's disease, G6PD Deficiency, cystic
fibrosis, hemochromatosis, Wilson disease. Polycystic Kidney Disease.
* * ‫ ﻣﺮﺽ ﺍﻟﺘﻜﺴﺮﺍﻟﻔﻮﻟﻰ‬،‫ ﻣﺮﺽ ﻏﻮﺷﺮ‬،‫ ﺃﻣﺮﺍﺽ ﺍﻟﻜﺮﻭﻣﻮﺳﻮﻣﺎﺕ‬،‫ ﺗﺸﻮﻫﺎﺕ ﺍﻷﻋﻀﺎﺀ ﺍﻟﺘﻨﺎﺳﻠﻴﺔ‬،‫ﺍﻟﻌﻀﻼﺕ ﺍﻟﺸﻮﻛﻲ‬
‫ﺗﻜﻴﺲ‬,‫ﻣﺮﺽ ﻭﻳﻠﺴﻮﻥ‬, (‫ ﻣﺮﺽ ﺗﻜﺪﺱ ﺍﻟﺤﺪﻳﺪ )ﻫﻴﻤﻮﻛﺮﻭﻣﺎﺗﻮﺳﻴﺲ‬،‫( ﺍﻟﺘﻠﻴﻒ ﺍﻟﻜﻴﺴﻲ ﻟﻠﺮﺋﺔ‬G6PD)
‫ﺍﻟﻜﻠﻴﺘﻴﻦ ﺍﻟﺨﻠﻔﻰ ﺍﻟﻮﺭﺍﺋﻰ‬

Have you been diagnosed with any of following eye diseases limited to: ،‫ ﻣﻴﺎﺓ ﺯﺭﻗﺎﺀ‬،‫ ﻣﻴﺎﺓ ﺑﻴﻀﺎﺀ‬:‫ﻫﻞ ﺗﻢ ﺗﺸﺨﻴﺼﻚ ﺑﺄﻱ ﻣﻦ ﺃﻣﺮﺍﺽ ﺍﻟﻌﻴﻦ ﺍﻟﺘﺎﻟﻴﺔ ﻓﻘﻂ‬
Cataract, Glaucoma, Retinal diseases. * * ‫ﺃﻣﺮﺍﺽ ﺍﻟﺸﺒﻜﻴﺔ‬
Have you been diagnosed with any of the following bone diseases limited ‫ ﺍﻹﻧﺰﻻﻕ ﺍﻟﻐﻀﺮﻭﻓﻲ‬:‫ﻫﻞ ﺗﻢ ﺗﺸﺨﻴﺼﻚ ﺑﺄﻱ ﻣﻦ ﺃﻣﺮﺍﺽ ﺍﻟﻌﻈﺎﻡ ﺍﻟﺘﺎﻟﻴﺔ ﻓﻘﻂ‬
to:Vertebral disc prolapse (moderate or severe), Scoliosis (moderate or severe)**, or ligament
tears, osteoarthritis (moderate or severe )
* * ‫ﺗﻤﺰﻕ ﺍﻷﺭﺑﻄﺔ‬،‫ﺍﻟﺘﻬﺎﺏ ﺍﻟﻤﻔﺎﺻﻞ‬،‫ﺇﻧﺤﺮﺍﻑ ﺍﻟﻌﻤﻮﺩ ﺍﻟﻔﻘﺮﻱ‬,‫ﺍﻟﺪﻳﺴﻚ‬

Pregnant Female Only ‫ﻟﻸﻧﺜﻰ ﺍﻟﺤﺎﻣﻞ ﻓﻘﻂ‬

‫ﺣﻤﻞ ﺣﺎﻟﻲ ﺟﻨﻴﻦ ﻭﺍﺣﺪ‬
Current Single Pregnancy
* *
‫ﺣﻤﻞ ﺣﺎﻟﻲ ﻣﻊ ﻗﻴﺼﺮﻳﺔ ﺳﺎﺑﻘﺔ‬
Current Single Pregnancy with Previous CS Delivery
* *
‫ﺣﻤﻞ ﺣﺎﻟﻲ ﻣﺘﻌﺪﺩ ﺍﻷﺟﻨﺔ‬
Current Multiple Pregnancy
* *
Expected delivery date .. / .. / .... ‫ﺗﺎﺭﻳﺦ ﺍﻟﻮﻻﺩﺓ ﺍﻟﻤﺘﻮﻗﻊ‬
Employee and dependents details that need to be added ‫ﺑﻴﺎﻧﺎﺕ ﺍﻟﻤﻮﻇﻒ ﻭﺃﻓﺮﺍﺩ ﺍﻟﻌﺎﺋﻠﺔ ﺍﻟﻤﺮﺍﺩ ﺇﺿﺎﻓﺘﻬﻢ‬
In case of a yes answer above, please declare the case in the table below ‫ ﺍﻟﺮﺟﺎﺀ ﺫﻛﺮ ﺍﻟﺤﺎﻟﺔ ﻓﻲ ﺍﻟﺠﺪﻭﻝ ﺃﺩﻧﺎﻩ‬،‫ﻓﻲ ﺣﺎﻟﺔ ﺍﻹﺟﺎﺑﺔ ﺑﻨﻌﻢ ﺃﻋﻼﻩ‬
‫ﺇﺳﻢ ﻣﻘﺪﻡ ﺍﻟﺨﺪﻣﺔ‬ ‫ﺍﻟﺤﺎﻟﺔ‬ ‫ﺭﻗﻢ ﺍﻟﺠﻮﺍﻝ‬ ‫ﺍﻟﻄﻮﻝ‬ ‫ﺍﻟﻮﺯﻥ‬ ‫ﺭﻗﻢ ﺍﻟﻬﻮﻳﺔ‬ ‫ﺍﻟﻘﺮﺍﺑﺔ‬ ‫ﺍﻟﺠﻨﺲ‬ ‫ ﺃﻓﺮﺍﺩ ﺍﻟﻌﺎﺋﻠﺔ‬/ ‫ﺍﺳﻢ ﺍﻟﻤﻮﻇﻒ‬ ‫ﻡ‬
2375154362 Child Male / ‫ ﺫﻛﺮ‬Mohammed Abdullah Khaliqu 1
2
3
4
5
Undertakings : ‫ﺍﻹﻗﺮﺍﺭ ﻭﺍﻟﺘﻔﻮﻳﺾ‬
1- I hereby undertake that all the above information is correct and the acceptance of my ‫ﻭﺍﻟﻤﻌﻠﻮﻣﺎﺕ ﺍﻟﻤﺬﻛﻮﺭﺓ ﺃﻋﻼﻩ ﻛﺎﻣﻠﺔ ﻭﺻﺤﻴﺤﺔ ﻭﺑﻨﺎﺀ ﻋﻠﻴﻪ ﻓﺈﻥ ﻗﺒﻮﻝ ﺍﻟﻄﻠﺐ ﺳﻴﺘﻢ‬: ‫ ﺃﻗﺮ ﺃﻥ ﺍﻟﺒﻴﺎﻧﺎﺕ‬-1
enrollment will be on the basis of such information and that Malath Cooperative Insurance ‫ﻋﻠﻰ ﺃﺳﺎﺱ ﻫﺬﻩ ﺍﻟﺒﻴﺎﻧﺎﺕ ﻭﺃﻥ ﺷﺮﻛﺔ ﻣﻼﺫ ﻟﻠﺘﺄﻣﻴﻦ ﺍﻟﺘﻌﺎﻭﻧﻲ ﻟﻬﺎ ﺍﻟﺤﻖ ﻓﻲ ﺍﻻﺗﺼﺎﻝ ﺑﺎﻟﻤﺴﺘﺸﻔﻴﺎﺕ ﺍﻟﺘﻲ‬
Company has the right to contact the hospital(s) I deal with to collect any ‫ﺃﺗﻌﺎﻣﻞ ﻣﻌﻬﺎ ﻟﺘﺰﻭﻳﺪﻫﺎ ﺑﺄﻱ ﻣﻌﻠﻮﻣﺎﺕ ﻃﺒﻴﺔ ﻗﺪ ﺗﺤﺘﺎﺝ ﺇﻟﻴﻬﺎ ﻟﺘﻘﻴﻴﻢ ﺍﻟﻤﺨﺎﻃﺮ‬
medical information needed to assess the risk(s).

2- I agree that Malath Cooperative Insurance Company has the right to reject the ‫ ﺃﻭﺍﻓﻖ ﻋﻠﻰ ﺃﺣﻘﻴﺔ ﺷﺮﻛﺔ ﻣﻼﺫ ﻟﻠﺘﺄﻣﻴﻦ ﻓﻲ ﺭﻓﺾ ﺍﻟﻤﻄﺎﻟﺒﺔ ﺃﻭ ﺍﻟﺘﻐﻄﻴﺔ ﻛﻠﻴﺎ ﻋﻨﺪ ﻋﺪﻡ ﺍﻹﻓﺼﺎﺡ ﻋﻦ ﻭﺟﻮﺩ ﺃﻱ ﻣﻦ ﺍﻟﺤﺎﻻﺕ‬-2
coverage/claims in full in case of no declaration of any cases prior to the contractual date or ‫ﺍﻟﻤﺬﻛﻮﺭﺓ ﺃﻋﻼﻩ ﺍﻟﺘﻲ ﻧﺸﺄﺕ ﻗﺒﻞ ﺗﺎﺭﻳﺦ ﺍﻟﺘﻌﺎﻗﺪ ﺃﻭ ﻗﺒﻞ ﺗﺴﺠﻴﻞ ﺃﻭ ﺇﺿﺎﻓﺔ ﻋﻀﻮ ﺧﻼﻝ ﻓﺘﺮﺓ ﺳﺮﻳﺎﻥ ﺍﻟﻌﻘﺪ‬
before enrolling or adding a new member during the contract.

3- I hereby confirm reading and understanding all points presented in this form and I agree that ‫ ﺃﻗﺮﺑﺄﻧﻲ ﻗﺪ ﻗﺮﺃﺕ ﻭﻓﻬﻤﺖ ﺟﻤﻴﻊ ﻣﺎ ﺟﺎﺀ ﻓﻲ ﻫﺬﺍ ﺍﻟﻨﻤﻮﺫﺝ ﻛﻤﺎ ﺃﺗﻌﻬﺪ ﺑﺄﻥ ﻋﺪﻡ ﺇﺷﺎﺭﺗﻲ ﺃﻣﺎﻡ ﺃﻱ ﻣﻦ‬-3
not marking any case is understood as “Nothing requires declaration” and I sign on these ‫ﺍﻟﺤﺎﻻﺕ ﺍﻟﻤﺬﻛﻮﺭﺓ ﺃﻋﻼﻩ ﻳﻌﺘﺒﺮ ﺑﻤﺜﺎﺑﺔ ﻧﻔﻲ ﻭﺟﻮﺩ ﻣﺎﻳﺴﺘﺤﻖ ﺍﻹﻓﺼﺎﺡ ﻋﻨﻪ ﻭﻋﻠﻴﻪ ﺃﻭﻗﻊ‬
basis.
4- Failure to fill the weight and height information will result in refusal to cover
the cost of obesity surgery. ‫ ﻋﺪﻡ ﺗﻌﺒﺌﺔ ﺑﻴﺎﻧﺎﺕ ﺍﻟﻄﻮﻝ ﻭﺍﻟﻮﺯﻥ ﺳﻴﺆﺩﻱ ﺇﻟﻰ ﺭﻓﺾ ﺗﻐﻄﻴﺔ ﺗﻜﺎﻟﻴﻒ ﻋﻤﻠﻴﺔ ﺟﺮﺍﺣﺔ ﺍﻟﺴﻤﻨﺔ ﺍﻟﻤﻔﺮﻃﺔ‬-4

Entity's stamp ‫ﺧﺘﻢ ﺟﻬﺔ ﺍﻟﻌﻤﻞ‬ Insured Signature ‫ﺗﻮﻗﻴﻊ ﺍﻟﻤﻮﻇﻒ‬ Date ‫ﺍﻟﺘﺎﺭﻳﺦ‬
.. / .. / ....

New_Health_Insurance.rdf Page 23 of 39 V.20 13-DEC-2023 01:30 PM

 ‫ﻧﻤﻮﺫﺝ ﺍﻻﻓﺼﺎﺡ ﺍﻟﻄﺒﻲ ﺍﻟﻤﻮﺣﺪ‬
Unified Medical Declaration Form
Product Code: A-MLTH-2-C-08-014
Dear Insured: ‫ﻋﺰﻳﺰﻱ ﺍﻟﻤﺆﻣﻦ ﻟﻪ‬
Please Fill out the form correctly for the purpose of pricing and to ensured that you and your ‫ﻧﺄﻣﻞ ﻗﻴﺎﻣﻚ ﺑﺘﻌﺒﺌﺔ ﻫﺬﺍ ﺍﻟﻨﻤﻮﺫﺝ ﺑﺎﻟﺸﻜﻞ ﺍﻟﺼﺤﻴﺢ ﻟﻐﺮﺽ ﺍﻟﺘﺴﻌﻴﺮ ﻭﻟﻀﻤﺎﻥ ﺣﺼﻮﻟﻚ ﻭﺃﻓﺮﺍﺩ ﺃﺳﺮﺗﻚ ﻋﻠﻰ ﺧﺪﻣﺎﺕ‬
family receive health care services as required according to your unfied policy benefit ‫ﺍﻟﺮﻋﺎﻳﺔ ﺍﻟﺼﺤﻴﺔ ﺑﺎﻟﺸﻜﻞ ﺍﻟﻤﻄﻠﻮﺏ ﺣﺴﺐ ﻣﻨﺎﻓﻊ ﺍﻟﻮﺛﻴﻘﺔ ﺍﻟﻤﻮﺣﺪﺓ‬

Addition ‫ﺇﺿﺎﻓﺔ‬ New ‫ﺟﺪﻳﺪ‬ Type ‫ﻧﻮﻉ ﺍﻟﻄﻠﺐ‬

CR No 7011507360 ‫ﺍﻟﺴﺠﻞ ﺍﻟﺘﺠﺎﺭﻱ‬ Entity Name HADDAJ AL HIJAZ EST ‫ﺃﺳﻢ ﺍﻟﻤﻨﺸﺄﺓ‬
Mobile No 0549072872 ‫ﺭﻗﻢ ﺍﻟﺠﻮﺍﻝ‬ Kaleem Hafiz - Mohammad ‫ﺍﺳﻢ ﺍﻟﻤﻮﻇﻒ‬
ID Number 2 0 1 7 3 9 6 9 7 5 ‫ﺭﻗﻢ ﺍﻟﻬﻮﻳﺔ‬
Male / ‫ﺫﻛﺮ‬ India
Gender ‫ ﺍﻟﺠﻨﺲ‬Nationality ‫ ﺍﻟﺠﻨﺴﻴﺔ‬Marital status Married R ‫ﻣﺘﺰﻭﺝ‬ Single * ‫ﺃﻋﺰﺏ‬ ‫ﺍﻟﺤﺎﻟﺔ ﺍﻻﺟﺘﻤﺎﻋﻴﺔ‬
Please declare any of the below cases by marking P under the word Yes ‫ ﻓﻲ ﺍﻟﻤﺮﺑﻊ ﺗﺤﺖ ﻛﻠﻤﺔ ﻧﻌﻢ‬P ‫ﻳﺮﺟﻰ ﺍﻹﻓﺼﺎﺡ ﻋﻦ ﻭﺟﻮﺩ ﺃﻱ ﻣﻦ ﺍﻟﺤﺎﻻﺕ ﺍﺩﻧﺎﻩ ﺑﻮﺿﻊ ﺇﺷﺎﺭﺓ‬
"Below Undeclared Medical Case May Not Be Covered" No / ‫ﻻ‬ Yes / ‫ﻧﻌـﻢ‬ "‫"ﻟﻦ ﺗﺘﻢ ﺍﻟﺘﻐﻄﻴﺔ ﺍﻟﺘﺄﻣﻴﻨﻴﺔ ﻟﻠﺤﺎﻻﺕ ﺃﺩﻧﺎﻩ ﻓﻰ ﺣﺎﻝ ﻋﺪﻡ ﺍﻹﻓﺼﺎﺡ ﻋﻨﻬﺎ‬
Any hospital admission during last 12 months. ‫ ﺷﻬﺮ‬12 ‫ﻫﻞ ﺗﻢ ﺍﻟﺘﻨﻮﻳﻢ ﺑﺎﻟﻤﺴﺘﺸﻔﻰ ﺧﻼﻝ ﺃﺧﺮ‬
"Admission: registering as an admitted patient at the hospital until the following morning "
* * " ‫ ﺗﺴﺠﻴﻞ ﺍﻟﺸﺨﺺ ﺍﻟﻤﺆﻣﻦ ﻟﻪ ﻛﻤﺮﻳﺾ ﻣﻨﻮﻡ ﻓﻲ ﺍﻟﻤﺴﺘﺸﻔﻰ ﺣﺘﻰ ﺻﺒﺎﺡ ﺍﻟﻴﻮﻡ ﺍﻟﺘﺎﻟﻲ‬: ‫" ﺍﻟﺘﻨﻮﻳﻢ‬

Have you been diagnosed with any of the following chronic disease limited ‫ﻫﻞ ﺗﻢ ﺗﺸﺨﻴﺼﻚ ﺑﺄﻯ ﻣﻦ ﺍﻷﻣﺮﺍﺽ ﺍﻟﺘﺎﻟﻴﺔ ﻓﻘﻂ‬
to:Autism, listed Benign Tumor (Breast tumors, fibroid uterus, benign prostatic hyperplasia, ‫ﺃﻭﺭﺍﻡ ﺃﻭ‬,‫ﺗﻀﺨﻢ ﺍﻟﺒﺮﻭﺳﺘﺎﺗﺎ ﺍﻟﺤﻤﻴﺪ‬,‫ ﺃﻭﺭﺍﻡ ﺍﻟﺮﺣﻢ ﺍﻟﻠﻴﻔﻰ‬, ‫ﺍﻻﻭﺭﺍﻡ ﺍﻟﺤﻤﻴﺪﺓ ﺍﻟﺘﺎﻟﻴﺔ )ﺃﻭﺭﺍﻡ ﺍﻟﺜﺪﻯ‬,‫ﺍﻷﻭﺭﺍﻡ ﺍﻟﺴﺮﻃﺎﻧﻴﺔ‬,‫ﺍﻟﺘﻮﺣﺪ‬
thyroid goiter and parathyroid glands, live tumors, colon tumors). Malignant tumors, listed ‫ﺃﻣﺮﺍﺽ ﺍﻟﻘﻠﺐ ﺍﻟﺘﺎﻟﻴﺔ)ﺃﻣﺮﺍﺽ ﺷﺮﺍﻳﻴﻦ ﻭﺻﻤﺎﻣﺎﺕ ﺗﻀﺨﻢ ﺍﻟﻐﺪﺓ ﺍﻟﺪﺭﻗﻴﺔ‬, (‫ﺃﻭﺭﺍﻡ ﺍﻟﻘﻮﻟﻮﻥ‬, ‫ﻭﺃﻭﺭﺍﻡ ﺍﻻﻟﻜﺒﺪ‬,‫ﻭ ﺍﻟﺠﺎﺭ ﺍﻟﺪﺭﻗﻴﺔ‬
Cardiac diseases coronary and valve heart diseases, heart failure, cardiac fibrillation
myocardial infraction, heart clots). Chronic Hepatitis C. Gallstones Sever Kidney failure (stage
* * ‫ﺍﻻﻟﺘﻬﺎﺏ ﺍﻟﻜﺒﺪﻯ ﺍﻟﻔﻴﺮﻭﺳﻰ ﺍﻟﻤﺰﻣﻦ‬.( ‫ﺍﻟﺮﺟﻔﺎﻥ ﺍﻟﻘﻠﺒﻰ ﻭﺟﻠﻄﺎﺕ ﺍﻟﻘﻠﺐ‬, ‫ﻓﺸﻞ ﻋﻀﻠﺔ ﺍﻟﻘﻠﺐ‬, ‫ﺣﺼﻮﺍﺕ ﺍﻟﻤﺮﺍﺭﺓ ﺍﻟﻘﻠﺐ‬, ‫ﺝ ﻭﺳﻰ‬
,‫ ﺍﻟﺘﺮﺷﻴﺢ ﺍﻟﻜﻠﻮﻯ ﺃﻗﻞ ﻣﻦ‬,‫ ﺍﻟﻔﺸﻞ ﺍﻟﻜﻠﻮﻯﺍﻟﺸﺪﻳﺪ )ﺍﻟﻤﺮﺣﻠﺔ ﺍﻟﺨﺎﻣﺴﺔ ﻣﻦ ﺍﻣﺮﺍﺽ ﺍﻟﻜﻠﻰ ﺍﻟﺘﻰ ﺗﺴﺘﺪﻋﻰ ﺍﻟﻐﺴﻴﻞ ﺍﻟﻜﻠﻮﻯ‬15
5 Requiring dialysis, clearance of less tha 15 ml/ minute*). Urinary tract ‫ﻣﺮﺽ‬, ‫ﺩﻗﻴﻘﺔ(ﺣﺼﻮﺍﺕ ﺍﻟﻤﺴﺎﻟﻚ ﺍﻟﺒﻮﻟﻴﺔﺃﻣﺮﺍﺽ ﺍﻟﻤﻨﺎﻋﺔ ﺍﻟﺘﺎﻟﻴﺔ )ﺍﻟﺬﺋﺒﺔ ﺍﻟﺤﻤﺮﺍﺀﻭﺍﻟﺘﻬﺎﺏ ﺍﻟﻤﻔﺎﺻﻞ ﺍﻟﺮﻭﻣﺎﺗﻴﺰﻣﻴﺔﻭ ﺍﻟﺼﺪﻓﻴﺔ‬/‫ﻣﻞ‬
stones, hernias. Autoimmune disease (lupus, rheumatoid arthritis, psoriasis, Crohn's disease, ‫ﺍﻟﺘﻬﺎﺏ ﺍﻟﻘﻮﻟﻮﻥ ﺍﻟﺘﻘﺮﺣﻰ‬, ‫ﻛﺮﻭﻧﺰ‬,
ulcerative colitis,multiple sclerosis, celiac disease) ‫ﺣﺴﺎﺳﻴﺔ ﺍﻟﻘﻤﺢ‬, ‫ﺍﻟﺘﺼﻠﺐ ﺍﻟﻠﻮﻳﺤﻰ‬

Have you been diagnosed with any of the following congenital disorder or
hereditary diseases limited to: Cerebral palsy, Sickle cell disorder, Thalassemia, ‫ﻫﻞ ﺗﻢ ﺗﺸﺨﻴﺼﻚ ﺑﺄﻱ ﻣﻦ ﺍﻷﻣﺮﺍﺽ ﺍﻟﻮﺭﺍﺛﻴﺔ ﺃﻭ ﺍﻟﺘﺸﻮﻫﺎﺕ ﺍﻟﺨﻠﻘﻴﺔ ﺍﻟﺘﺎﻟﻴﺔ ﻓﻘﻂ‬
hemophilia, metabolic diseases, Hydrocephalus, spinal muscle atrophy, genital ‫ ﺿﻤﻮﺭ‬،‫ ﺃﺳﺘﺴﻘﺎﺀ ﺍﻟﺮﺃﺱ‬،‫ ﺃﻣﺮﺍﺽ ﺍﻟﺘﻤﺜﻴﻞ ﺍﻟﻐﺬﺍﺋﻲ‬،‫ ﺍﻟﻬﻴﻤﻮﻓﻴﻠﻴﺎ‬،‫ ﺍﻟﺘﻼﺳﻴﻤﻴﺎ‬،‫ﺍﺿﻄﺮﺍﺏ ﺍﻟﺨﻼﻳﺎ ﺍﻟﻤﻨﺠﻠﻴﺔ‬, ‫ﺍﻟﺸﻠﻞ ﺍﻟﺪﻣﺎﻏﻰ‬
malformations, chromosomal abnormalities. Gaucher's disease, G6PD Deficiency, cystic
fibrosis, hemochromatosis, Wilson disease. Polycystic Kidney Disease.
* * ‫ ﻣﺮﺽ ﺍﻟﺘﻜﺴﺮﺍﻟﻔﻮﻟﻰ‬،‫ ﻣﺮﺽ ﻏﻮﺷﺮ‬،‫ ﺃﻣﺮﺍﺽ ﺍﻟﻜﺮﻭﻣﻮﺳﻮﻣﺎﺕ‬،‫ ﺗﺸﻮﻫﺎﺕ ﺍﻷﻋﻀﺎﺀ ﺍﻟﺘﻨﺎﺳﻠﻴﺔ‬،‫ﺍﻟﻌﻀﻼﺕ ﺍﻟﺸﻮﻛﻲ‬
‫ﺗﻜﻴﺲ‬,‫ﻣﺮﺽ ﻭﻳﻠﺴﻮﻥ‬, (‫ ﻣﺮﺽ ﺗﻜﺪﺱ ﺍﻟﺤﺪﻳﺪ )ﻫﻴﻤﻮﻛﺮﻭﻣﺎﺗﻮﺳﻴﺲ‬،‫( ﺍﻟﺘﻠﻴﻒ ﺍﻟﻜﻴﺴﻲ ﻟﻠﺮﺋﺔ‬G6PD)
‫ﺍﻟﻜﻠﻴﺘﻴﻦ ﺍﻟﺨﻠﻔﻰ ﺍﻟﻮﺭﺍﺋﻰ‬

Have you been diagnosed with any of following eye diseases limited to: ،‫ ﻣﻴﺎﺓ ﺯﺭﻗﺎﺀ‬،‫ ﻣﻴﺎﺓ ﺑﻴﻀﺎﺀ‬:‫ﻫﻞ ﺗﻢ ﺗﺸﺨﻴﺼﻚ ﺑﺄﻱ ﻣﻦ ﺃﻣﺮﺍﺽ ﺍﻟﻌﻴﻦ ﺍﻟﺘﺎﻟﻴﺔ ﻓﻘﻂ‬
Cataract, Glaucoma, Retinal diseases. * * ‫ﺃﻣﺮﺍﺽ ﺍﻟﺸﺒﻜﻴﺔ‬
Have you been diagnosed with any of the following bone diseases limited ‫ ﺍﻹﻧﺰﻻﻕ ﺍﻟﻐﻀﺮﻭﻓﻲ‬:‫ﻫﻞ ﺗﻢ ﺗﺸﺨﻴﺼﻚ ﺑﺄﻱ ﻣﻦ ﺃﻣﺮﺍﺽ ﺍﻟﻌﻈﺎﻡ ﺍﻟﺘﺎﻟﻴﺔ ﻓﻘﻂ‬
to:Vertebral disc prolapse (moderate or severe), Scoliosis (moderate or severe)**, or ligament
tears, osteoarthritis (moderate or severe )
* * ‫ﺗﻤﺰﻕ ﺍﻷﺭﺑﻄﺔ‬،‫ﺍﻟﺘﻬﺎﺏ ﺍﻟﻤﻔﺎﺻﻞ‬،‫ﺇﻧﺤﺮﺍﻑ ﺍﻟﻌﻤﻮﺩ ﺍﻟﻔﻘﺮﻱ‬,‫ﺍﻟﺪﻳﺴﻚ‬

Pregnant Female Only ‫ﻟﻸﻧﺜﻰ ﺍﻟﺤﺎﻣﻞ ﻓﻘﻂ‬

‫ﺣﻤﻞ ﺣﺎﻟﻲ ﺟﻨﻴﻦ ﻭﺍﺣﺪ‬
Current Single Pregnancy
* *
‫ﺣﻤﻞ ﺣﺎﻟﻲ ﻣﻊ ﻗﻴﺼﺮﻳﺔ ﺳﺎﺑﻘﺔ‬
Current Single Pregnancy with Previous CS Delivery
* *
‫ﺣﻤﻞ ﺣﺎﻟﻲ ﻣﺘﻌﺪﺩ ﺍﻷﺟﻨﺔ‬
Current Multiple Pregnancy
* *
Expected delivery date .. / .. / .... ‫ﺗﺎﺭﻳﺦ ﺍﻟﻮﻻﺩﺓ ﺍﻟﻤﺘﻮﻗﻊ‬
Employee and dependents details that need to be added ‫ﺑﻴﺎﻧﺎﺕ ﺍﻟﻤﻮﻇﻒ ﻭﺃﻓﺮﺍﺩ ﺍﻟﻌﺎﺋﻠﺔ ﺍﻟﻤﺮﺍﺩ ﺇﺿﺎﻓﺘﻬﻢ‬
In case of a yes answer above, please declare the case in the table below ‫ ﺍﻟﺮﺟﺎﺀ ﺫﻛﺮ ﺍﻟﺤﺎﻟﺔ ﻓﻲ ﺍﻟﺠﺪﻭﻝ ﺃﺩﻧﺎﻩ‬،‫ﻓﻲ ﺣﺎﻟﺔ ﺍﻹﺟﺎﺑﺔ ﺑﻨﻌﻢ ﺃﻋﻼﻩ‬
‫ﺇﺳﻢ ﻣﻘﺪﻡ ﺍﻟﺨﺪﻣﺔ‬ ‫ﺍﻟﺤﺎﻟﺔ‬ ‫ﺭﻗﻢ ﺍﻟﺠﻮﺍﻝ‬ ‫ﺍﻟﻄﻮﻝ‬ ‫ﺍﻟﻮﺯﻥ‬ ‫ﺭﻗﻢ ﺍﻟﻬﻮﻳﺔ‬ ‫ﺍﻟﻘﺮﺍﺑﺔ‬ ‫ﺍﻟﺠﻨﺲ‬ ‫ ﺃﻓﺮﺍﺩ ﺍﻟﻌﺎﺋﻠﺔ‬/ ‫ﺍﺳﻢ ﺍﻟﻤﻮﻇﻒ‬ ‫ﻡ‬
2017396975 Employee Male / ‫ ﺫﻛﺮ‬Kaleem Hafiz - Mohammad 1
2
3
4
5
Undertakings : ‫ﺍﻹﻗﺮﺍﺭ ﻭﺍﻟﺘﻔﻮﻳﺾ‬
1- I hereby undertake that all the above information is correct and the acceptance of my ‫ﻭﺍﻟﻤﻌﻠﻮﻣﺎﺕ ﺍﻟﻤﺬﻛﻮﺭﺓ ﺃﻋﻼﻩ ﻛﺎﻣﻠﺔ ﻭﺻﺤﻴﺤﺔ ﻭﺑﻨﺎﺀ ﻋﻠﻴﻪ ﻓﺈﻥ ﻗﺒﻮﻝ ﺍﻟﻄﻠﺐ ﺳﻴﺘﻢ‬: ‫ ﺃﻗﺮ ﺃﻥ ﺍﻟﺒﻴﺎﻧﺎﺕ‬-1
enrollment will be on the basis of such information and that Malath Cooperative Insurance ‫ﻋﻠﻰ ﺃﺳﺎﺱ ﻫﺬﻩ ﺍﻟﺒﻴﺎﻧﺎﺕ ﻭﺃﻥ ﺷﺮﻛﺔ ﻣﻼﺫ ﻟﻠﺘﺄﻣﻴﻦ ﺍﻟﺘﻌﺎﻭﻧﻲ ﻟﻬﺎ ﺍﻟﺤﻖ ﻓﻲ ﺍﻻﺗﺼﺎﻝ ﺑﺎﻟﻤﺴﺘﺸﻔﻴﺎﺕ ﺍﻟﺘﻲ‬
Company has the right to contact the hospital(s) I deal with to collect any ‫ﺃﺗﻌﺎﻣﻞ ﻣﻌﻬﺎ ﻟﺘﺰﻭﻳﺪﻫﺎ ﺑﺄﻱ ﻣﻌﻠﻮﻣﺎﺕ ﻃﺒﻴﺔ ﻗﺪ ﺗﺤﺘﺎﺝ ﺇﻟﻴﻬﺎ ﻟﺘﻘﻴﻴﻢ ﺍﻟﻤﺨﺎﻃﺮ‬
medical information needed to assess the risk(s).

2- I agree that Malath Cooperative Insurance Company has the right to reject the ‫ ﺃﻭﺍﻓﻖ ﻋﻠﻰ ﺃﺣﻘﻴﺔ ﺷﺮﻛﺔ ﻣﻼﺫ ﻟﻠﺘﺄﻣﻴﻦ ﻓﻲ ﺭﻓﺾ ﺍﻟﻤﻄﺎﻟﺒﺔ ﺃﻭ ﺍﻟﺘﻐﻄﻴﺔ ﻛﻠﻴﺎ ﻋﻨﺪ ﻋﺪﻡ ﺍﻹﻓﺼﺎﺡ ﻋﻦ ﻭﺟﻮﺩ ﺃﻱ ﻣﻦ ﺍﻟﺤﺎﻻﺕ‬-2
coverage/claims in full in case of no declaration of any cases prior to the contractual date or ‫ﺍﻟﻤﺬﻛﻮﺭﺓ ﺃﻋﻼﻩ ﺍﻟﺘﻲ ﻧﺸﺄﺕ ﻗﺒﻞ ﺗﺎﺭﻳﺦ ﺍﻟﺘﻌﺎﻗﺪ ﺃﻭ ﻗﺒﻞ ﺗﺴﺠﻴﻞ ﺃﻭ ﺇﺿﺎﻓﺔ ﻋﻀﻮ ﺧﻼﻝ ﻓﺘﺮﺓ ﺳﺮﻳﺎﻥ ﺍﻟﻌﻘﺪ‬
before enrolling or adding a new member during the contract.

3- I hereby confirm reading and understanding all points presented in this form and I agree that ‫ ﺃﻗﺮﺑﺄﻧﻲ ﻗﺪ ﻗﺮﺃﺕ ﻭﻓﻬﻤﺖ ﺟﻤﻴﻊ ﻣﺎ ﺟﺎﺀ ﻓﻲ ﻫﺬﺍ ﺍﻟﻨﻤﻮﺫﺝ ﻛﻤﺎ ﺃﺗﻌﻬﺪ ﺑﺄﻥ ﻋﺪﻡ ﺇﺷﺎﺭﺗﻲ ﺃﻣﺎﻡ ﺃﻱ ﻣﻦ‬-3
not marking any case is understood as “Nothing requires declaration” and I sign on these ‫ﺍﻟﺤﺎﻻﺕ ﺍﻟﻤﺬﻛﻮﺭﺓ ﺃﻋﻼﻩ ﻳﻌﺘﺒﺮ ﺑﻤﺜﺎﺑﺔ ﻧﻔﻲ ﻭﺟﻮﺩ ﻣﺎﻳﺴﺘﺤﻖ ﺍﻹﻓﺼﺎﺡ ﻋﻨﻪ ﻭﻋﻠﻴﻪ ﺃﻭﻗﻊ‬
basis.
4- Failure to fill the weight and height information will result in refusal to cover
the cost of obesity surgery. ‫ ﻋﺪﻡ ﺗﻌﺒﺌﺔ ﺑﻴﺎﻧﺎﺕ ﺍﻟﻄﻮﻝ ﻭﺍﻟﻮﺯﻥ ﺳﻴﺆﺩﻱ ﺇﻟﻰ ﺭﻓﺾ ﺗﻐﻄﻴﺔ ﺗﻜﺎﻟﻴﻒ ﻋﻤﻠﻴﺔ ﺟﺮﺍﺣﺔ ﺍﻟﺴﻤﻨﺔ ﺍﻟﻤﻔﺮﻃﺔ‬-4

Entity's stamp ‫ﺧﺘﻢ ﺟﻬﺔ ﺍﻟﻌﻤﻞ‬ Insured Signature ‫ﺗﻮﻗﻴﻊ ﺍﻟﻤﻮﻇﻒ‬ Date ‫ﺍﻟﺘﺎﺭﻳﺦ‬
.. / .. / ....

New_Health_Insurance.rdf Page 24 of 39 V.20 13-DEC-2023 01:30 PM

 ‫ﻧﻤﻮﺫﺝ ﺍﻻﻓﺼﺎﺡ ﺍﻟﻄﺒﻲ ﺍﻟﻤﻮﺣﺪ‬
Unified Medical Declaration Form
Product Code: A-MLTH-2-C-08-014
Dear Insured: ‫ﻋﺰﻳﺰﻱ ﺍﻟﻤﺆﻣﻦ ﻟﻪ‬
Please Fill out the form correctly for the purpose of pricing and to ensured that you and your ‫ﻧﺄﻣﻞ ﻗﻴﺎﻣﻚ ﺑﺘﻌﺒﺌﺔ ﻫﺬﺍ ﺍﻟﻨﻤﻮﺫﺝ ﺑﺎﻟﺸﻜﻞ ﺍﻟﺼﺤﻴﺢ ﻟﻐﺮﺽ ﺍﻟﺘﺴﻌﻴﺮ ﻭﻟﻀﻤﺎﻥ ﺣﺼﻮﻟﻚ ﻭﺃﻓﺮﺍﺩ ﺃﺳﺮﺗﻚ ﻋﻠﻰ ﺧﺪﻣﺎﺕ‬
family receive health care services as required according to your unfied policy benefit ‫ﺍﻟﺮﻋﺎﻳﺔ ﺍﻟﺼﺤﻴﺔ ﺑﺎﻟﺸﻜﻞ ﺍﻟﻤﻄﻠﻮﺏ ﺣﺴﺐ ﻣﻨﺎﻓﻊ ﺍﻟﻮﺛﻴﻘﺔ ﺍﻟﻤﻮﺣﺪﺓ‬

Addition ‫ﺇﺿﺎﻓﺔ‬ New ‫ﺟﺪﻳﺪ‬ Type ‫ﻧﻮﻉ ﺍﻟﻄﻠﺐ‬

CR No 7011507360 ‫ﺍﻟﺴﺠﻞ ﺍﻟﺘﺠﺎﺭﻱ‬ Entity Name HADDAJ AL HIJAZ EST ‫ﺃﺳﻢ ﺍﻟﻤﻨﺸﺄﺓ‬
Mobile No 0549072872 ‫ﺭﻗﻢ ﺍﻟﺠﻮﺍﻝ‬ Shafiqa - - Ahmad ‫ﺍﺳﻢ ﺍﻟﻤﻮﻇﻒ‬
ID Number 2 0 1 7 3 9 6 9 8 3 ‫ﺭﻗﻢ ﺍﻟﻬﻮﻳﺔ‬
Gender Female / ‫ﺍﻟﺠﻨﺲ ﺃﻧﺜﻰ‬ Nationality India ‫ ﺍﻟﺠﻨﺴﻴﺔ‬Marital status Married R ‫ﻣﺘﺰﻭﺝ‬ Single * ‫ﺃﻋﺰﺏ‬ ‫ﺍﻟﺤﺎﻟﺔ ﺍﻻﺟﺘﻤﺎﻋﻴﺔ‬
Please declare any of the below cases by marking P under the word Yes ‫ ﻓﻲ ﺍﻟﻤﺮﺑﻊ ﺗﺤﺖ ﻛﻠﻤﺔ ﻧﻌﻢ‬P ‫ﻳﺮﺟﻰ ﺍﻹﻓﺼﺎﺡ ﻋﻦ ﻭﺟﻮﺩ ﺃﻱ ﻣﻦ ﺍﻟﺤﺎﻻﺕ ﺍﺩﻧﺎﻩ ﺑﻮﺿﻊ ﺇﺷﺎﺭﺓ‬
"Below Undeclared Medical Case May Not Be Covered" No / ‫ﻻ‬ Yes / ‫ﻧﻌـﻢ‬ "‫"ﻟﻦ ﺗﺘﻢ ﺍﻟﺘﻐﻄﻴﺔ ﺍﻟﺘﺄﻣﻴﻨﻴﺔ ﻟﻠﺤﺎﻻﺕ ﺃﺩﻧﺎﻩ ﻓﻰ ﺣﺎﻝ ﻋﺪﻡ ﺍﻹﻓﺼﺎﺡ ﻋﻨﻬﺎ‬
Any hospital admission during last 12 months. ‫ ﺷﻬﺮ‬12 ‫ﻫﻞ ﺗﻢ ﺍﻟﺘﻨﻮﻳﻢ ﺑﺎﻟﻤﺴﺘﺸﻔﻰ ﺧﻼﻝ ﺃﺧﺮ‬
"Admission: registering as an admitted patient at the hospital until the following morning "
* * " ‫ ﺗﺴﺠﻴﻞ ﺍﻟﺸﺨﺺ ﺍﻟﻤﺆﻣﻦ ﻟﻪ ﻛﻤﺮﻳﺾ ﻣﻨﻮﻡ ﻓﻲ ﺍﻟﻤﺴﺘﺸﻔﻰ ﺣﺘﻰ ﺻﺒﺎﺡ ﺍﻟﻴﻮﻡ ﺍﻟﺘﺎﻟﻲ‬: ‫" ﺍﻟﺘﻨﻮﻳﻢ‬

Have you been diagnosed with any of the following chronic disease limited ‫ﻫﻞ ﺗﻢ ﺗﺸﺨﻴﺼﻚ ﺑﺄﻯ ﻣﻦ ﺍﻷﻣﺮﺍﺽ ﺍﻟﺘﺎﻟﻴﺔ ﻓﻘﻂ‬
to:Autism, listed Benign Tumor (Breast tumors, fibroid uterus, benign prostatic hyperplasia, ‫ﺃﻭﺭﺍﻡ ﺃﻭ‬,‫ﺗﻀﺨﻢ ﺍﻟﺒﺮﻭﺳﺘﺎﺗﺎ ﺍﻟﺤﻤﻴﺪ‬,‫ ﺃﻭﺭﺍﻡ ﺍﻟﺮﺣﻢ ﺍﻟﻠﻴﻔﻰ‬, ‫ﺍﻻﻭﺭﺍﻡ ﺍﻟﺤﻤﻴﺪﺓ ﺍﻟﺘﺎﻟﻴﺔ )ﺃﻭﺭﺍﻡ ﺍﻟﺜﺪﻯ‬,‫ﺍﻷﻭﺭﺍﻡ ﺍﻟﺴﺮﻃﺎﻧﻴﺔ‬,‫ﺍﻟﺘﻮﺣﺪ‬
thyroid goiter and parathyroid glands, live tumors, colon tumors). Malignant tumors, listed ‫ﺃﻣﺮﺍﺽ ﺍﻟﻘﻠﺐ ﺍﻟﺘﺎﻟﻴﺔ)ﺃﻣﺮﺍﺽ ﺷﺮﺍﻳﻴﻦ ﻭﺻﻤﺎﻣﺎﺕ ﺗﻀﺨﻢ ﺍﻟﻐﺪﺓ ﺍﻟﺪﺭﻗﻴﺔ‬, (‫ﺃﻭﺭﺍﻡ ﺍﻟﻘﻮﻟﻮﻥ‬, ‫ﻭﺃﻭﺭﺍﻡ ﺍﻻﻟﻜﺒﺪ‬,‫ﻭ ﺍﻟﺠﺎﺭ ﺍﻟﺪﺭﻗﻴﺔ‬
Cardiac diseases coronary and valve heart diseases, heart failure, cardiac fibrillation
myocardial infraction, heart clots). Chronic Hepatitis C. Gallstones Sever Kidney failure (stage
* * ‫ﺍﻻﻟﺘﻬﺎﺏ ﺍﻟﻜﺒﺪﻯ ﺍﻟﻔﻴﺮﻭﺳﻰ ﺍﻟﻤﺰﻣﻦ‬.( ‫ﺍﻟﺮﺟﻔﺎﻥ ﺍﻟﻘﻠﺒﻰ ﻭﺟﻠﻄﺎﺕ ﺍﻟﻘﻠﺐ‬, ‫ﻓﺸﻞ ﻋﻀﻠﺔ ﺍﻟﻘﻠﺐ‬, ‫ﺣﺼﻮﺍﺕ ﺍﻟﻤﺮﺍﺭﺓ ﺍﻟﻘﻠﺐ‬, ‫ﺝ ﻭﺳﻰ‬
,‫ ﺍﻟﺘﺮﺷﻴﺢ ﺍﻟﻜﻠﻮﻯ ﺃﻗﻞ ﻣﻦ‬,‫ ﺍﻟﻔﺸﻞ ﺍﻟﻜﻠﻮﻯﺍﻟﺸﺪﻳﺪ )ﺍﻟﻤﺮﺣﻠﺔ ﺍﻟﺨﺎﻣﺴﺔ ﻣﻦ ﺍﻣﺮﺍﺽ ﺍﻟﻜﻠﻰ ﺍﻟﺘﻰ ﺗﺴﺘﺪﻋﻰ ﺍﻟﻐﺴﻴﻞ ﺍﻟﻜﻠﻮﻯ‬15
5 Requiring dialysis, clearance of less tha 15 ml/ minute*). Urinary tract ‫ﻣﺮﺽ‬, ‫ﺩﻗﻴﻘﺔ(ﺣﺼﻮﺍﺕ ﺍﻟﻤﺴﺎﻟﻚ ﺍﻟﺒﻮﻟﻴﺔﺃﻣﺮﺍﺽ ﺍﻟﻤﻨﺎﻋﺔ ﺍﻟﺘﺎﻟﻴﺔ )ﺍﻟﺬﺋﺒﺔ ﺍﻟﺤﻤﺮﺍﺀﻭﺍﻟﺘﻬﺎﺏ ﺍﻟﻤﻔﺎﺻﻞ ﺍﻟﺮﻭﻣﺎﺗﻴﺰﻣﻴﺔﻭ ﺍﻟﺼﺪﻓﻴﺔ‬/‫ﻣﻞ‬
stones, hernias. Autoimmune disease (lupus, rheumatoid arthritis, psoriasis, Crohn's disease, ‫ﺍﻟﺘﻬﺎﺏ ﺍﻟﻘﻮﻟﻮﻥ ﺍﻟﺘﻘﺮﺣﻰ‬, ‫ﻛﺮﻭﻧﺰ‬,
ulcerative colitis,multiple sclerosis, celiac disease) ‫ﺣﺴﺎﺳﻴﺔ ﺍﻟﻘﻤﺢ‬, ‫ﺍﻟﺘﺼﻠﺐ ﺍﻟﻠﻮﻳﺤﻰ‬

Have you been diagnosed with any of the following congenital disorder or
hereditary diseases limited to: Cerebral palsy, Sickle cell disorder, Thalassemia, ‫ﻫﻞ ﺗﻢ ﺗﺸﺨﻴﺼﻚ ﺑﺄﻱ ﻣﻦ ﺍﻷﻣﺮﺍﺽ ﺍﻟﻮﺭﺍﺛﻴﺔ ﺃﻭ ﺍﻟﺘﺸﻮﻫﺎﺕ ﺍﻟﺨﻠﻘﻴﺔ ﺍﻟﺘﺎﻟﻴﺔ ﻓﻘﻂ‬
hemophilia, metabolic diseases, Hydrocephalus, spinal muscle atrophy, genital ‫ ﺿﻤﻮﺭ‬،‫ ﺃﺳﺘﺴﻘﺎﺀ ﺍﻟﺮﺃﺱ‬،‫ ﺃﻣﺮﺍﺽ ﺍﻟﺘﻤﺜﻴﻞ ﺍﻟﻐﺬﺍﺋﻲ‬،‫ ﺍﻟﻬﻴﻤﻮﻓﻴﻠﻴﺎ‬،‫ ﺍﻟﺘﻼﺳﻴﻤﻴﺎ‬،‫ﺍﺿﻄﺮﺍﺏ ﺍﻟﺨﻼﻳﺎ ﺍﻟﻤﻨﺠﻠﻴﺔ‬, ‫ﺍﻟﺸﻠﻞ ﺍﻟﺪﻣﺎﻏﻰ‬
malformations, chromosomal abnormalities. Gaucher's disease, G6PD Deficiency, cystic
fibrosis, hemochromatosis, Wilson disease. Polycystic Kidney Disease.
* * ‫ ﻣﺮﺽ ﺍﻟﺘﻜﺴﺮﺍﻟﻔﻮﻟﻰ‬،‫ ﻣﺮﺽ ﻏﻮﺷﺮ‬،‫ ﺃﻣﺮﺍﺽ ﺍﻟﻜﺮﻭﻣﻮﺳﻮﻣﺎﺕ‬،‫ ﺗﺸﻮﻫﺎﺕ ﺍﻷﻋﻀﺎﺀ ﺍﻟﺘﻨﺎﺳﻠﻴﺔ‬،‫ﺍﻟﻌﻀﻼﺕ ﺍﻟﺸﻮﻛﻲ‬
‫ﺗﻜﻴﺲ‬,‫ﻣﺮﺽ ﻭﻳﻠﺴﻮﻥ‬, (‫ ﻣﺮﺽ ﺗﻜﺪﺱ ﺍﻟﺤﺪﻳﺪ )ﻫﻴﻤﻮﻛﺮﻭﻣﺎﺗﻮﺳﻴﺲ‬،‫( ﺍﻟﺘﻠﻴﻒ ﺍﻟﻜﻴﺴﻲ ﻟﻠﺮﺋﺔ‬G6PD)
‫ﺍﻟﻜﻠﻴﺘﻴﻦ ﺍﻟﺨﻠﻔﻰ ﺍﻟﻮﺭﺍﺋﻰ‬

Have you been diagnosed with any of following eye diseases limited to: ،‫ ﻣﻴﺎﺓ ﺯﺭﻗﺎﺀ‬،‫ ﻣﻴﺎﺓ ﺑﻴﻀﺎﺀ‬:‫ﻫﻞ ﺗﻢ ﺗﺸﺨﻴﺼﻚ ﺑﺄﻱ ﻣﻦ ﺃﻣﺮﺍﺽ ﺍﻟﻌﻴﻦ ﺍﻟﺘﺎﻟﻴﺔ ﻓﻘﻂ‬
Cataract, Glaucoma, Retinal diseases. * * ‫ﺃﻣﺮﺍﺽ ﺍﻟﺸﺒﻜﻴﺔ‬
Have you been diagnosed with any of the following bone diseases limited ‫ ﺍﻹﻧﺰﻻﻕ ﺍﻟﻐﻀﺮﻭﻓﻲ‬:‫ﻫﻞ ﺗﻢ ﺗﺸﺨﻴﺼﻚ ﺑﺄﻱ ﻣﻦ ﺃﻣﺮﺍﺽ ﺍﻟﻌﻈﺎﻡ ﺍﻟﺘﺎﻟﻴﺔ ﻓﻘﻂ‬
to:Vertebral disc prolapse (moderate or severe), Scoliosis (moderate or severe)**, or ligament
tears, osteoarthritis (moderate or severe )
* * ‫ﺗﻤﺰﻕ ﺍﻷﺭﺑﻄﺔ‬،‫ﺍﻟﺘﻬﺎﺏ ﺍﻟﻤﻔﺎﺻﻞ‬،‫ﺇﻧﺤﺮﺍﻑ ﺍﻟﻌﻤﻮﺩ ﺍﻟﻔﻘﺮﻱ‬,‫ﺍﻟﺪﻳﺴﻚ‬

Pregnant Female Only ‫ﻟﻸﻧﺜﻰ ﺍﻟﺤﺎﻣﻞ ﻓﻘﻂ‬

‫ﺣﻤﻞ ﺣﺎﻟﻲ ﺟﻨﻴﻦ ﻭﺍﺣﺪ‬
Current Single Pregnancy
* *
‫ﺣﻤﻞ ﺣﺎﻟﻲ ﻣﻊ ﻗﻴﺼﺮﻳﺔ ﺳﺎﺑﻘﺔ‬
Current Single Pregnancy with Previous CS Delivery
* *
‫ﺣﻤﻞ ﺣﺎﻟﻲ ﻣﺘﻌﺪﺩ ﺍﻷﺟﻨﺔ‬
Current Multiple Pregnancy
* *
Expected delivery date .. / .. / .... ‫ﺗﺎﺭﻳﺦ ﺍﻟﻮﻻﺩﺓ ﺍﻟﻤﺘﻮﻗﻊ‬
Employee and dependents details that need to be added ‫ﺑﻴﺎﻧﺎﺕ ﺍﻟﻤﻮﻇﻒ ﻭﺃﻓﺮﺍﺩ ﺍﻟﻌﺎﺋﻠﺔ ﺍﻟﻤﺮﺍﺩ ﺇﺿﺎﻓﺘﻬﻢ‬
In case of a yes answer above, please declare the case in the table below ‫ ﺍﻟﺮﺟﺎﺀ ﺫﻛﺮ ﺍﻟﺤﺎﻟﺔ ﻓﻲ ﺍﻟﺠﺪﻭﻝ ﺃﺩﻧﺎﻩ‬،‫ﻓﻲ ﺣﺎﻟﺔ ﺍﻹﺟﺎﺑﺔ ﺑﻨﻌﻢ ﺃﻋﻼﻩ‬
‫ﺇﺳﻢ ﻣﻘﺪﻡ ﺍﻟﺨﺪﻣﺔ‬ ‫ﺍﻟﺤﺎﻟﺔ‬ ‫ﺭﻗﻢ ﺍﻟﺠﻮﺍﻝ‬ ‫ﺍﻟﻄﻮﻝ‬ ‫ﺍﻟﻮﺯﻥ‬ ‫ﺭﻗﻢ ﺍﻟﻬﻮﻳﺔ‬ ‫ﺍﻟﻘﺮﺍﺑﺔ‬ ‫ﺍﻟﺠﻨﺲ‬ ‫ ﺃﻓﺮﺍﺩ ﺍﻟﻌﺎﺋﻠﺔ‬/ ‫ﺍﺳﻢ ﺍﻟﻤﻮﻇﻒ‬ ‫ﻡ‬
2017396983 Spouse Female / ‫ ﺃﻧﺜﻰ‬Shafiqa - - Ahmad 1
2
3
4
5
Undertakings : ‫ﺍﻹﻗﺮﺍﺭ ﻭﺍﻟﺘﻔﻮﻳﺾ‬
1- I hereby undertake that all the above information is correct and the acceptance of my ‫ﻭﺍﻟﻤﻌﻠﻮﻣﺎﺕ ﺍﻟﻤﺬﻛﻮﺭﺓ ﺃﻋﻼﻩ ﻛﺎﻣﻠﺔ ﻭﺻﺤﻴﺤﺔ ﻭﺑﻨﺎﺀ ﻋﻠﻴﻪ ﻓﺈﻥ ﻗﺒﻮﻝ ﺍﻟﻄﻠﺐ ﺳﻴﺘﻢ‬: ‫ ﺃﻗﺮ ﺃﻥ ﺍﻟﺒﻴﺎﻧﺎﺕ‬-1
enrollment will be on the basis of such information and that Malath Cooperative Insurance ‫ﻋﻠﻰ ﺃﺳﺎﺱ ﻫﺬﻩ ﺍﻟﺒﻴﺎﻧﺎﺕ ﻭﺃﻥ ﺷﺮﻛﺔ ﻣﻼﺫ ﻟﻠﺘﺄﻣﻴﻦ ﺍﻟﺘﻌﺎﻭﻧﻲ ﻟﻬﺎ ﺍﻟﺤﻖ ﻓﻲ ﺍﻻﺗﺼﺎﻝ ﺑﺎﻟﻤﺴﺘﺸﻔﻴﺎﺕ ﺍﻟﺘﻲ‬
Company has the right to contact the hospital(s) I deal with to collect any ‫ﺃﺗﻌﺎﻣﻞ ﻣﻌﻬﺎ ﻟﺘﺰﻭﻳﺪﻫﺎ ﺑﺄﻱ ﻣﻌﻠﻮﻣﺎﺕ ﻃﺒﻴﺔ ﻗﺪ ﺗﺤﺘﺎﺝ ﺇﻟﻴﻬﺎ ﻟﺘﻘﻴﻴﻢ ﺍﻟﻤﺨﺎﻃﺮ‬
medical information needed to assess the risk(s).

2- I agree that Malath Cooperative Insurance Company has the right to reject the ‫ ﺃﻭﺍﻓﻖ ﻋﻠﻰ ﺃﺣﻘﻴﺔ ﺷﺮﻛﺔ ﻣﻼﺫ ﻟﻠﺘﺄﻣﻴﻦ ﻓﻲ ﺭﻓﺾ ﺍﻟﻤﻄﺎﻟﺒﺔ ﺃﻭ ﺍﻟﺘﻐﻄﻴﺔ ﻛﻠﻴﺎ ﻋﻨﺪ ﻋﺪﻡ ﺍﻹﻓﺼﺎﺡ ﻋﻦ ﻭﺟﻮﺩ ﺃﻱ ﻣﻦ ﺍﻟﺤﺎﻻﺕ‬-2
coverage/claims in full in case of no declaration of any cases prior to the contractual date or ‫ﺍﻟﻤﺬﻛﻮﺭﺓ ﺃﻋﻼﻩ ﺍﻟﺘﻲ ﻧﺸﺄﺕ ﻗﺒﻞ ﺗﺎﺭﻳﺦ ﺍﻟﺘﻌﺎﻗﺪ ﺃﻭ ﻗﺒﻞ ﺗﺴﺠﻴﻞ ﺃﻭ ﺇﺿﺎﻓﺔ ﻋﻀﻮ ﺧﻼﻝ ﻓﺘﺮﺓ ﺳﺮﻳﺎﻥ ﺍﻟﻌﻘﺪ‬
before enrolling or adding a new member during the contract.

3- I hereby confirm reading and understanding all points presented in this form and I agree that ‫ ﺃﻗﺮﺑﺄﻧﻲ ﻗﺪ ﻗﺮﺃﺕ ﻭﻓﻬﻤﺖ ﺟﻤﻴﻊ ﻣﺎ ﺟﺎﺀ ﻓﻲ ﻫﺬﺍ ﺍﻟﻨﻤﻮﺫﺝ ﻛﻤﺎ ﺃﺗﻌﻬﺪ ﺑﺄﻥ ﻋﺪﻡ ﺇﺷﺎﺭﺗﻲ ﺃﻣﺎﻡ ﺃﻱ ﻣﻦ‬-3
not marking any case is understood as “Nothing requires declaration” and I sign on these ‫ﺍﻟﺤﺎﻻﺕ ﺍﻟﻤﺬﻛﻮﺭﺓ ﺃﻋﻼﻩ ﻳﻌﺘﺒﺮ ﺑﻤﺜﺎﺑﺔ ﻧﻔﻲ ﻭﺟﻮﺩ ﻣﺎﻳﺴﺘﺤﻖ ﺍﻹﻓﺼﺎﺡ ﻋﻨﻪ ﻭﻋﻠﻴﻪ ﺃﻭﻗﻊ‬
basis.
4- Failure to fill the weight and height information will result in refusal to cover
the cost of obesity surgery. ‫ ﻋﺪﻡ ﺗﻌﺒﺌﺔ ﺑﻴﺎﻧﺎﺕ ﺍﻟﻄﻮﻝ ﻭﺍﻟﻮﺯﻥ ﺳﻴﺆﺩﻱ ﺇﻟﻰ ﺭﻓﺾ ﺗﻐﻄﻴﺔ ﺗﻜﺎﻟﻴﻒ ﻋﻤﻠﻴﺔ ﺟﺮﺍﺣﺔ ﺍﻟﺴﻤﻨﺔ ﺍﻟﻤﻔﺮﻃﺔ‬-4

Entity's stamp ‫ﺧﺘﻢ ﺟﻬﺔ ﺍﻟﻌﻤﻞ‬ Insured Signature ‫ﺗﻮﻗﻴﻊ ﺍﻟﻤﻮﻇﻒ‬ Date ‫ﺍﻟﺘﺎﺭﻳﺦ‬
.. / .. / ....

New_Health_Insurance.rdf Page 25 of 39 V.20 13-DEC-2023 01:30 PM

 ‫ﻧﻤﻮﺫﺝ ﺍﻻﻓﺼﺎﺡ ﺍﻟﻄﺒﻲ ﺍﻟﻤﻮﺣﺪ‬
Unified Medical Declaration Form
Product Code: A-MLTH-2-C-08-014
Dear Insured: ‫ﻋﺰﻳﺰﻱ ﺍﻟﻤﺆﻣﻦ ﻟﻪ‬
Please Fill out the form correctly for the purpose of pricing and to ensured that you and your ‫ﻧﺄﻣﻞ ﻗﻴﺎﻣﻚ ﺑﺘﻌﺒﺌﺔ ﻫﺬﺍ ﺍﻟﻨﻤﻮﺫﺝ ﺑﺎﻟﺸﻜﻞ ﺍﻟﺼﺤﻴﺢ ﻟﻐﺮﺽ ﺍﻟﺘﺴﻌﻴﺮ ﻭﻟﻀﻤﺎﻥ ﺣﺼﻮﻟﻚ ﻭﺃﻓﺮﺍﺩ ﺃﺳﺮﺗﻚ ﻋﻠﻰ ﺧﺪﻣﺎﺕ‬
family receive health care services as required according to your unfied policy benefit ‫ﺍﻟﺮﻋﺎﻳﺔ ﺍﻟﺼﺤﻴﺔ ﺑﺎﻟﺸﻜﻞ ﺍﻟﻤﻄﻠﻮﺏ ﺣﺴﺐ ﻣﻨﺎﻓﻊ ﺍﻟﻮﺛﻴﻘﺔ ﺍﻟﻤﻮﺣﺪﺓ‬

Addition ‫ﺇﺿﺎﻓﺔ‬ New ‫ﺟﺪﻳﺪ‬ Type ‫ﻧﻮﻉ ﺍﻟﻄﻠﺐ‬

CR No 7011507360 ‫ﺍﻟﺴﺠﻞ ﺍﻟﺘﺠﺎﺭﻱ‬ Entity Name HADDAJ AL HIJAZ EST ‫ﺃﺳﻢ ﺍﻟﻤﻨﺸﺄﺓ‬
Mobile No 0549072872 ‫ﺭﻗﻢ ﺍﻟﺠﻮﺍﻝ‬ Sana Kalimahmed - Hafiz ‫ﺍﺳﻢ ﺍﻟﻤﻮﻇﻒ‬
ID Number 2 2 2 2 8 3 0 9 7 4 ‫ﺭﻗﻢ ﺍﻟﻬﻮﻳﺔ‬
Gender Female / ‫ﺍﻟﺠﻨﺲ ﺃﻧﺜﻰ‬ Nationality India ‫ ﺍﻟﺠﻨﺴﻴﺔ‬Marital status Married * ‫ﻣﺘﺰﻭﺝ‬ Single R ‫ﺃﻋﺰﺏ‬ ‫ﺍﻟﺤﺎﻟﺔ ﺍﻻﺟﺘﻤﺎﻋﻴﺔ‬
Please declare any of the below cases by marking P under the word Yes ‫ ﻓﻲ ﺍﻟﻤﺮﺑﻊ ﺗﺤﺖ ﻛﻠﻤﺔ ﻧﻌﻢ‬P ‫ﻳﺮﺟﻰ ﺍﻹﻓﺼﺎﺡ ﻋﻦ ﻭﺟﻮﺩ ﺃﻱ ﻣﻦ ﺍﻟﺤﺎﻻﺕ ﺍﺩﻧﺎﻩ ﺑﻮﺿﻊ ﺇﺷﺎﺭﺓ‬
"Below Undeclared Medical Case May Not Be Covered" No / ‫ﻻ‬ Yes / ‫ﻧﻌـﻢ‬ "‫"ﻟﻦ ﺗﺘﻢ ﺍﻟﺘﻐﻄﻴﺔ ﺍﻟﺘﺄﻣﻴﻨﻴﺔ ﻟﻠﺤﺎﻻﺕ ﺃﺩﻧﺎﻩ ﻓﻰ ﺣﺎﻝ ﻋﺪﻡ ﺍﻹﻓﺼﺎﺡ ﻋﻨﻬﺎ‬
Any hospital admission during last 12 months. ‫ ﺷﻬﺮ‬12 ‫ﻫﻞ ﺗﻢ ﺍﻟﺘﻨﻮﻳﻢ ﺑﺎﻟﻤﺴﺘﺸﻔﻰ ﺧﻼﻝ ﺃﺧﺮ‬
"Admission: registering as an admitted patient at the hospital until the following morning "
* * " ‫ ﺗﺴﺠﻴﻞ ﺍﻟﺸﺨﺺ ﺍﻟﻤﺆﻣﻦ ﻟﻪ ﻛﻤﺮﻳﺾ ﻣﻨﻮﻡ ﻓﻲ ﺍﻟﻤﺴﺘﺸﻔﻰ ﺣﺘﻰ ﺻﺒﺎﺡ ﺍﻟﻴﻮﻡ ﺍﻟﺘﺎﻟﻲ‬: ‫" ﺍﻟﺘﻨﻮﻳﻢ‬

Have you been diagnosed with any of the following chronic disease limited ‫ﻫﻞ ﺗﻢ ﺗﺸﺨﻴﺼﻚ ﺑﺄﻯ ﻣﻦ ﺍﻷﻣﺮﺍﺽ ﺍﻟﺘﺎﻟﻴﺔ ﻓﻘﻂ‬
to:Autism, listed Benign Tumor (Breast tumors, fibroid uterus, benign prostatic hyperplasia, ‫ﺃﻭﺭﺍﻡ ﺃﻭ‬,‫ﺗﻀﺨﻢ ﺍﻟﺒﺮﻭﺳﺘﺎﺗﺎ ﺍﻟﺤﻤﻴﺪ‬,‫ ﺃﻭﺭﺍﻡ ﺍﻟﺮﺣﻢ ﺍﻟﻠﻴﻔﻰ‬, ‫ﺍﻻﻭﺭﺍﻡ ﺍﻟﺤﻤﻴﺪﺓ ﺍﻟﺘﺎﻟﻴﺔ )ﺃﻭﺭﺍﻡ ﺍﻟﺜﺪﻯ‬,‫ﺍﻷﻭﺭﺍﻡ ﺍﻟﺴﺮﻃﺎﻧﻴﺔ‬,‫ﺍﻟﺘﻮﺣﺪ‬
thyroid goiter and parathyroid glands, live tumors, colon tumors). Malignant tumors, listed ‫ﺃﻣﺮﺍﺽ ﺍﻟﻘﻠﺐ ﺍﻟﺘﺎﻟﻴﺔ)ﺃﻣﺮﺍﺽ ﺷﺮﺍﻳﻴﻦ ﻭﺻﻤﺎﻣﺎﺕ ﺗﻀﺨﻢ ﺍﻟﻐﺪﺓ ﺍﻟﺪﺭﻗﻴﺔ‬, (‫ﺃﻭﺭﺍﻡ ﺍﻟﻘﻮﻟﻮﻥ‬, ‫ﻭﺃﻭﺭﺍﻡ ﺍﻻﻟﻜﺒﺪ‬,‫ﻭ ﺍﻟﺠﺎﺭ ﺍﻟﺪﺭﻗﻴﺔ‬
Cardiac diseases coronary and valve heart diseases, heart failure, cardiac fibrillation
myocardial infraction, heart clots). Chronic Hepatitis C. Gallstones Sever Kidney failure (stage
* * ‫ﺍﻻﻟﺘﻬﺎﺏ ﺍﻟﻜﺒﺪﻯ ﺍﻟﻔﻴﺮﻭﺳﻰ ﺍﻟﻤﺰﻣﻦ‬.( ‫ﺍﻟﺮﺟﻔﺎﻥ ﺍﻟﻘﻠﺒﻰ ﻭﺟﻠﻄﺎﺕ ﺍﻟﻘﻠﺐ‬, ‫ﻓﺸﻞ ﻋﻀﻠﺔ ﺍﻟﻘﻠﺐ‬, ‫ﺣﺼﻮﺍﺕ ﺍﻟﻤﺮﺍﺭﺓ ﺍﻟﻘﻠﺐ‬, ‫ﺝ ﻭﺳﻰ‬
,‫ ﺍﻟﺘﺮﺷﻴﺢ ﺍﻟﻜﻠﻮﻯ ﺃﻗﻞ ﻣﻦ‬,‫ ﺍﻟﻔﺸﻞ ﺍﻟﻜﻠﻮﻯﺍﻟﺸﺪﻳﺪ )ﺍﻟﻤﺮﺣﻠﺔ ﺍﻟﺨﺎﻣﺴﺔ ﻣﻦ ﺍﻣﺮﺍﺽ ﺍﻟﻜﻠﻰ ﺍﻟﺘﻰ ﺗﺴﺘﺪﻋﻰ ﺍﻟﻐﺴﻴﻞ ﺍﻟﻜﻠﻮﻯ‬15
5 Requiring dialysis, clearance of less tha 15 ml/ minute*). Urinary tract ‫ﻣﺮﺽ‬, ‫ﺩﻗﻴﻘﺔ(ﺣﺼﻮﺍﺕ ﺍﻟﻤﺴﺎﻟﻚ ﺍﻟﺒﻮﻟﻴﺔﺃﻣﺮﺍﺽ ﺍﻟﻤﻨﺎﻋﺔ ﺍﻟﺘﺎﻟﻴﺔ )ﺍﻟﺬﺋﺒﺔ ﺍﻟﺤﻤﺮﺍﺀﻭﺍﻟﺘﻬﺎﺏ ﺍﻟﻤﻔﺎﺻﻞ ﺍﻟﺮﻭﻣﺎﺗﻴﺰﻣﻴﺔﻭ ﺍﻟﺼﺪﻓﻴﺔ‬/‫ﻣﻞ‬
stones, hernias. Autoimmune disease (lupus, rheumatoid arthritis, psoriasis, Crohn's disease, ‫ﺍﻟﺘﻬﺎﺏ ﺍﻟﻘﻮﻟﻮﻥ ﺍﻟﺘﻘﺮﺣﻰ‬, ‫ﻛﺮﻭﻧﺰ‬,
ulcerative colitis,multiple sclerosis, celiac disease) ‫ﺣﺴﺎﺳﻴﺔ ﺍﻟﻘﻤﺢ‬, ‫ﺍﻟﺘﺼﻠﺐ ﺍﻟﻠﻮﻳﺤﻰ‬

Have you been diagnosed with any of the following congenital disorder or
hereditary diseases limited to: Cerebral palsy, Sickle cell disorder, Thalassemia, ‫ﻫﻞ ﺗﻢ ﺗﺸﺨﻴﺼﻚ ﺑﺄﻱ ﻣﻦ ﺍﻷﻣﺮﺍﺽ ﺍﻟﻮﺭﺍﺛﻴﺔ ﺃﻭ ﺍﻟﺘﺸﻮﻫﺎﺕ ﺍﻟﺨﻠﻘﻴﺔ ﺍﻟﺘﺎﻟﻴﺔ ﻓﻘﻂ‬
hemophilia, metabolic diseases, Hydrocephalus, spinal muscle atrophy, genital ‫ ﺿﻤﻮﺭ‬،‫ ﺃﺳﺘﺴﻘﺎﺀ ﺍﻟﺮﺃﺱ‬،‫ ﺃﻣﺮﺍﺽ ﺍﻟﺘﻤﺜﻴﻞ ﺍﻟﻐﺬﺍﺋﻲ‬،‫ ﺍﻟﻬﻴﻤﻮﻓﻴﻠﻴﺎ‬،‫ ﺍﻟﺘﻼﺳﻴﻤﻴﺎ‬،‫ﺍﺿﻄﺮﺍﺏ ﺍﻟﺨﻼﻳﺎ ﺍﻟﻤﻨﺠﻠﻴﺔ‬, ‫ﺍﻟﺸﻠﻞ ﺍﻟﺪﻣﺎﻏﻰ‬
malformations, chromosomal abnormalities. Gaucher's disease, G6PD Deficiency, cystic
fibrosis, hemochromatosis, Wilson disease. Polycystic Kidney Disease.
* * ‫ ﻣﺮﺽ ﺍﻟﺘﻜﺴﺮﺍﻟﻔﻮﻟﻰ‬،‫ ﻣﺮﺽ ﻏﻮﺷﺮ‬،‫ ﺃﻣﺮﺍﺽ ﺍﻟﻜﺮﻭﻣﻮﺳﻮﻣﺎﺕ‬،‫ ﺗﺸﻮﻫﺎﺕ ﺍﻷﻋﻀﺎﺀ ﺍﻟﺘﻨﺎﺳﻠﻴﺔ‬،‫ﺍﻟﻌﻀﻼﺕ ﺍﻟﺸﻮﻛﻲ‬
‫ﺗﻜﻴﺲ‬,‫ﻣﺮﺽ ﻭﻳﻠﺴﻮﻥ‬, (‫ ﻣﺮﺽ ﺗﻜﺪﺱ ﺍﻟﺤﺪﻳﺪ )ﻫﻴﻤﻮﻛﺮﻭﻣﺎﺗﻮﺳﻴﺲ‬،‫( ﺍﻟﺘﻠﻴﻒ ﺍﻟﻜﻴﺴﻲ ﻟﻠﺮﺋﺔ‬G6PD)
‫ﺍﻟﻜﻠﻴﺘﻴﻦ ﺍﻟﺨﻠﻔﻰ ﺍﻟﻮﺭﺍﺋﻰ‬

Have you been diagnosed with any of following eye diseases limited to: ،‫ ﻣﻴﺎﺓ ﺯﺭﻗﺎﺀ‬،‫ ﻣﻴﺎﺓ ﺑﻴﻀﺎﺀ‬:‫ﻫﻞ ﺗﻢ ﺗﺸﺨﻴﺼﻚ ﺑﺄﻱ ﻣﻦ ﺃﻣﺮﺍﺽ ﺍﻟﻌﻴﻦ ﺍﻟﺘﺎﻟﻴﺔ ﻓﻘﻂ‬
Cataract, Glaucoma, Retinal diseases. * * ‫ﺃﻣﺮﺍﺽ ﺍﻟﺸﺒﻜﻴﺔ‬
Have you been diagnosed with any of the following bone diseases limited ‫ ﺍﻹﻧﺰﻻﻕ ﺍﻟﻐﻀﺮﻭﻓﻲ‬:‫ﻫﻞ ﺗﻢ ﺗﺸﺨﻴﺼﻚ ﺑﺄﻱ ﻣﻦ ﺃﻣﺮﺍﺽ ﺍﻟﻌﻈﺎﻡ ﺍﻟﺘﺎﻟﻴﺔ ﻓﻘﻂ‬
to:Vertebral disc prolapse (moderate or severe), Scoliosis (moderate or severe)**, or ligament
tears, osteoarthritis (moderate or severe )
* * ‫ﺗﻤﺰﻕ ﺍﻷﺭﺑﻄﺔ‬،‫ﺍﻟﺘﻬﺎﺏ ﺍﻟﻤﻔﺎﺻﻞ‬،‫ﺇﻧﺤﺮﺍﻑ ﺍﻟﻌﻤﻮﺩ ﺍﻟﻔﻘﺮﻱ‬,‫ﺍﻟﺪﻳﺴﻚ‬

Pregnant Female Only ‫ﻟﻸﻧﺜﻰ ﺍﻟﺤﺎﻣﻞ ﻓﻘﻂ‬

‫ﺣﻤﻞ ﺣﺎﻟﻲ ﺟﻨﻴﻦ ﻭﺍﺣﺪ‬
Current Single Pregnancy
* *
‫ﺣﻤﻞ ﺣﺎﻟﻲ ﻣﻊ ﻗﻴﺼﺮﻳﺔ ﺳﺎﺑﻘﺔ‬
Current Single Pregnancy with Previous CS Delivery
* *
‫ﺣﻤﻞ ﺣﺎﻟﻲ ﻣﺘﻌﺪﺩ ﺍﻷﺟﻨﺔ‬
Current Multiple Pregnancy
* *
Expected delivery date .. / .. / .... ‫ﺗﺎﺭﻳﺦ ﺍﻟﻮﻻﺩﺓ ﺍﻟﻤﺘﻮﻗﻊ‬
Employee and dependents details that need to be added ‫ﺑﻴﺎﻧﺎﺕ ﺍﻟﻤﻮﻇﻒ ﻭﺃﻓﺮﺍﺩ ﺍﻟﻌﺎﺋﻠﺔ ﺍﻟﻤﺮﺍﺩ ﺇﺿﺎﻓﺘﻬﻢ‬
In case of a yes answer above, please declare the case in the table below ‫ ﺍﻟﺮﺟﺎﺀ ﺫﻛﺮ ﺍﻟﺤﺎﻟﺔ ﻓﻲ ﺍﻟﺠﺪﻭﻝ ﺃﺩﻧﺎﻩ‬،‫ﻓﻲ ﺣﺎﻟﺔ ﺍﻹﺟﺎﺑﺔ ﺑﻨﻌﻢ ﺃﻋﻼﻩ‬
‫ﺇﺳﻢ ﻣﻘﺪﻡ ﺍﻟﺨﺪﻣﺔ‬ ‫ﺍﻟﺤﺎﻟﺔ‬ ‫ﺭﻗﻢ ﺍﻟﺠﻮﺍﻝ‬ ‫ﺍﻟﻄﻮﻝ‬ ‫ﺍﻟﻮﺯﻥ‬ ‫ﺭﻗﻢ ﺍﻟﻬﻮﻳﺔ‬ ‫ﺍﻟﻘﺮﺍﺑﺔ‬ ‫ﺍﻟﺠﻨﺲ‬ ‫ ﺃﻓﺮﺍﺩ ﺍﻟﻌﺎﺋﻠﺔ‬/ ‫ﺍﺳﻢ ﺍﻟﻤﻮﻇﻒ‬ ‫ﻡ‬
2222830974 Child Female / ‫ ﺃﻧﺜﻰ‬Sana Kalimahmed - Hafiz 1
2
3
4
5
Undertakings : ‫ﺍﻹﻗﺮﺍﺭ ﻭﺍﻟﺘﻔﻮﻳﺾ‬
1- I hereby undertake that all the above information is correct and the acceptance of my ‫ﻭﺍﻟﻤﻌﻠﻮﻣﺎﺕ ﺍﻟﻤﺬﻛﻮﺭﺓ ﺃﻋﻼﻩ ﻛﺎﻣﻠﺔ ﻭﺻﺤﻴﺤﺔ ﻭﺑﻨﺎﺀ ﻋﻠﻴﻪ ﻓﺈﻥ ﻗﺒﻮﻝ ﺍﻟﻄﻠﺐ ﺳﻴﺘﻢ‬: ‫ ﺃﻗﺮ ﺃﻥ ﺍﻟﺒﻴﺎﻧﺎﺕ‬-1
enrollment will be on the basis of such information and that Malath Cooperative Insurance ‫ﻋﻠﻰ ﺃﺳﺎﺱ ﻫﺬﻩ ﺍﻟﺒﻴﺎﻧﺎﺕ ﻭﺃﻥ ﺷﺮﻛﺔ ﻣﻼﺫ ﻟﻠﺘﺄﻣﻴﻦ ﺍﻟﺘﻌﺎﻭﻧﻲ ﻟﻬﺎ ﺍﻟﺤﻖ ﻓﻲ ﺍﻻﺗﺼﺎﻝ ﺑﺎﻟﻤﺴﺘﺸﻔﻴﺎﺕ ﺍﻟﺘﻲ‬
Company has the right to contact the hospital(s) I deal with to collect any ‫ﺃﺗﻌﺎﻣﻞ ﻣﻌﻬﺎ ﻟﺘﺰﻭﻳﺪﻫﺎ ﺑﺄﻱ ﻣﻌﻠﻮﻣﺎﺕ ﻃﺒﻴﺔ ﻗﺪ ﺗﺤﺘﺎﺝ ﺇﻟﻴﻬﺎ ﻟﺘﻘﻴﻴﻢ ﺍﻟﻤﺨﺎﻃﺮ‬
medical information needed to assess the risk(s).

2- I agree that Malath Cooperative Insurance Company has the right to reject the ‫ ﺃﻭﺍﻓﻖ ﻋﻠﻰ ﺃﺣﻘﻴﺔ ﺷﺮﻛﺔ ﻣﻼﺫ ﻟﻠﺘﺄﻣﻴﻦ ﻓﻲ ﺭﻓﺾ ﺍﻟﻤﻄﺎﻟﺒﺔ ﺃﻭ ﺍﻟﺘﻐﻄﻴﺔ ﻛﻠﻴﺎ ﻋﻨﺪ ﻋﺪﻡ ﺍﻹﻓﺼﺎﺡ ﻋﻦ ﻭﺟﻮﺩ ﺃﻱ ﻣﻦ ﺍﻟﺤﺎﻻﺕ‬-2
coverage/claims in full in case of no declaration of any cases prior to the contractual date or ‫ﺍﻟﻤﺬﻛﻮﺭﺓ ﺃﻋﻼﻩ ﺍﻟﺘﻲ ﻧﺸﺄﺕ ﻗﺒﻞ ﺗﺎﺭﻳﺦ ﺍﻟﺘﻌﺎﻗﺪ ﺃﻭ ﻗﺒﻞ ﺗﺴﺠﻴﻞ ﺃﻭ ﺇﺿﺎﻓﺔ ﻋﻀﻮ ﺧﻼﻝ ﻓﺘﺮﺓ ﺳﺮﻳﺎﻥ ﺍﻟﻌﻘﺪ‬
before enrolling or adding a new member during the contract.

3- I hereby confirm reading and understanding all points presented in this form and I agree that ‫ ﺃﻗﺮﺑﺄﻧﻲ ﻗﺪ ﻗﺮﺃﺕ ﻭﻓﻬﻤﺖ ﺟﻤﻴﻊ ﻣﺎ ﺟﺎﺀ ﻓﻲ ﻫﺬﺍ ﺍﻟﻨﻤﻮﺫﺝ ﻛﻤﺎ ﺃﺗﻌﻬﺪ ﺑﺄﻥ ﻋﺪﻡ ﺇﺷﺎﺭﺗﻲ ﺃﻣﺎﻡ ﺃﻱ ﻣﻦ‬-3
not marking any case is understood as “Nothing requires declaration” and I sign on these ‫ﺍﻟﺤﺎﻻﺕ ﺍﻟﻤﺬﻛﻮﺭﺓ ﺃﻋﻼﻩ ﻳﻌﺘﺒﺮ ﺑﻤﺜﺎﺑﺔ ﻧﻔﻲ ﻭﺟﻮﺩ ﻣﺎﻳﺴﺘﺤﻖ ﺍﻹﻓﺼﺎﺡ ﻋﻨﻪ ﻭﻋﻠﻴﻪ ﺃﻭﻗﻊ‬
basis.
4- Failure to fill the weight and height information will result in refusal to cover
the cost of obesity surgery. ‫ ﻋﺪﻡ ﺗﻌﺒﺌﺔ ﺑﻴﺎﻧﺎﺕ ﺍﻟﻄﻮﻝ ﻭﺍﻟﻮﺯﻥ ﺳﻴﺆﺩﻱ ﺇﻟﻰ ﺭﻓﺾ ﺗﻐﻄﻴﺔ ﺗﻜﺎﻟﻴﻒ ﻋﻤﻠﻴﺔ ﺟﺮﺍﺣﺔ ﺍﻟﺴﻤﻨﺔ ﺍﻟﻤﻔﺮﻃﺔ‬-4

Entity's stamp ‫ﺧﺘﻢ ﺟﻬﺔ ﺍﻟﻌﻤﻞ‬ Insured Signature ‫ﺗﻮﻗﻴﻊ ﺍﻟﻤﻮﻇﻒ‬ Date ‫ﺍﻟﺘﺎﺭﻳﺦ‬
.. / .. / ....

New_Health_Insurance.rdf Page 26 of 39 V.20 13-DEC-2023 01:30 PM

 ‫ﻧﻤﻮﺫﺝ ﺍﻻﻓﺼﺎﺡ ﺍﻟﻄﺒﻲ ﺍﻟﻤﻮﺣﺪ‬
Unified Medical Declaration Form
Product Code: A-MLTH-2-C-08-014
Dear Insured: ‫ﻋﺰﻳﺰﻱ ﺍﻟﻤﺆﻣﻦ ﻟﻪ‬
Please Fill out the form correctly for the purpose of pricing and to ensured that you and your ‫ﻧﺄﻣﻞ ﻗﻴﺎﻣﻚ ﺑﺘﻌﺒﺌﺔ ﻫﺬﺍ ﺍﻟﻨﻤﻮﺫﺝ ﺑﺎﻟﺸﻜﻞ ﺍﻟﺼﺤﻴﺢ ﻟﻐﺮﺽ ﺍﻟﺘﺴﻌﻴﺮ ﻭﻟﻀﻤﺎﻥ ﺣﺼﻮﻟﻚ ﻭﺃﻓﺮﺍﺩ ﺃﺳﺮﺗﻚ ﻋﻠﻰ ﺧﺪﻣﺎﺕ‬
family receive health care services as required according to your unfied policy benefit ‫ﺍﻟﺮﻋﺎﻳﺔ ﺍﻟﺼﺤﻴﺔ ﺑﺎﻟﺸﻜﻞ ﺍﻟﻤﻄﻠﻮﺏ ﺣﺴﺐ ﻣﻨﺎﻓﻊ ﺍﻟﻮﺛﻴﻘﺔ ﺍﻟﻤﻮﺣﺪﺓ‬

Addition ‫ﺇﺿﺎﻓﺔ‬ New ‫ﺟﺪﻳﺪ‬ Type ‫ﻧﻮﻉ ﺍﻟﻄﻠﺐ‬

CR No 7011507360 ‫ﺍﻟﺴﺠﻞ ﺍﻟﺘﺠﺎﺭﻱ‬ Entity Name HADDAJ AL HIJAZ EST ‫ﺃﺳﻢ ﺍﻟﻤﻨﺸﺄﺓ‬
Mobile No 0531455109 ‫ﺭﻗﻢ ﺍﻟﺠﻮﺍﻝ‬ Yousuf Irshad - Abbasi ‫ﺍﺳﻢ ﺍﻟﻤﻮﻇﻒ‬
ID Number 2 1 2 1 3 2 3 4 0 2 ‫ﺭﻗﻢ ﺍﻟﻬﻮﻳﺔ‬
Male / ‫ﺫﻛﺮ‬ India
Gender ‫ ﺍﻟﺠﻨﺲ‬Nationality ‫ ﺍﻟﺠﻨﺴﻴﺔ‬Marital status Married * ‫ﻣﺘﺰﻭﺝ‬ Single R ‫ﺃﻋﺰﺏ‬ ‫ﺍﻟﺤﺎﻟﺔ ﺍﻻﺟﺘﻤﺎﻋﻴﺔ‬
Please declare any of the below cases by marking P under the word Yes ‫ ﻓﻲ ﺍﻟﻤﺮﺑﻊ ﺗﺤﺖ ﻛﻠﻤﺔ ﻧﻌﻢ‬P ‫ﻳﺮﺟﻰ ﺍﻹﻓﺼﺎﺡ ﻋﻦ ﻭﺟﻮﺩ ﺃﻱ ﻣﻦ ﺍﻟﺤﺎﻻﺕ ﺍﺩﻧﺎﻩ ﺑﻮﺿﻊ ﺇﺷﺎﺭﺓ‬
"Below Undeclared Medical Case May Not Be Covered" No / ‫ﻻ‬ Yes / ‫ﻧﻌـﻢ‬ "‫"ﻟﻦ ﺗﺘﻢ ﺍﻟﺘﻐﻄﻴﺔ ﺍﻟﺘﺄﻣﻴﻨﻴﺔ ﻟﻠﺤﺎﻻﺕ ﺃﺩﻧﺎﻩ ﻓﻰ ﺣﺎﻝ ﻋﺪﻡ ﺍﻹﻓﺼﺎﺡ ﻋﻨﻬﺎ‬
Any hospital admission during last 12 months. ‫ ﺷﻬﺮ‬12 ‫ﻫﻞ ﺗﻢ ﺍﻟﺘﻨﻮﻳﻢ ﺑﺎﻟﻤﺴﺘﺸﻔﻰ ﺧﻼﻝ ﺃﺧﺮ‬
"Admission: registering as an admitted patient at the hospital until the following morning "
* * " ‫ ﺗﺴﺠﻴﻞ ﺍﻟﺸﺨﺺ ﺍﻟﻤﺆﻣﻦ ﻟﻪ ﻛﻤﺮﻳﺾ ﻣﻨﻮﻡ ﻓﻲ ﺍﻟﻤﺴﺘﺸﻔﻰ ﺣﺘﻰ ﺻﺒﺎﺡ ﺍﻟﻴﻮﻡ ﺍﻟﺘﺎﻟﻲ‬: ‫" ﺍﻟﺘﻨﻮﻳﻢ‬

Have you been diagnosed with any of the following chronic disease limited ‫ﻫﻞ ﺗﻢ ﺗﺸﺨﻴﺼﻚ ﺑﺄﻯ ﻣﻦ ﺍﻷﻣﺮﺍﺽ ﺍﻟﺘﺎﻟﻴﺔ ﻓﻘﻂ‬
to:Autism, listed Benign Tumor (Breast tumors, fibroid uterus, benign prostatic hyperplasia, ‫ﺃﻭﺭﺍﻡ ﺃﻭ‬,‫ﺗﻀﺨﻢ ﺍﻟﺒﺮﻭﺳﺘﺎﺗﺎ ﺍﻟﺤﻤﻴﺪ‬,‫ ﺃﻭﺭﺍﻡ ﺍﻟﺮﺣﻢ ﺍﻟﻠﻴﻔﻰ‬, ‫ﺍﻻﻭﺭﺍﻡ ﺍﻟﺤﻤﻴﺪﺓ ﺍﻟﺘﺎﻟﻴﺔ )ﺃﻭﺭﺍﻡ ﺍﻟﺜﺪﻯ‬,‫ﺍﻷﻭﺭﺍﻡ ﺍﻟﺴﺮﻃﺎﻧﻴﺔ‬,‫ﺍﻟﺘﻮﺣﺪ‬
thyroid goiter and parathyroid glands, live tumors, colon tumors). Malignant tumors, listed ‫ﺃﻣﺮﺍﺽ ﺍﻟﻘﻠﺐ ﺍﻟﺘﺎﻟﻴﺔ)ﺃﻣﺮﺍﺽ ﺷﺮﺍﻳﻴﻦ ﻭﺻﻤﺎﻣﺎﺕ ﺗﻀﺨﻢ ﺍﻟﻐﺪﺓ ﺍﻟﺪﺭﻗﻴﺔ‬, (‫ﺃﻭﺭﺍﻡ ﺍﻟﻘﻮﻟﻮﻥ‬, ‫ﻭﺃﻭﺭﺍﻡ ﺍﻻﻟﻜﺒﺪ‬,‫ﻭ ﺍﻟﺠﺎﺭ ﺍﻟﺪﺭﻗﻴﺔ‬
Cardiac diseases coronary and valve heart diseases, heart failure, cardiac fibrillation
myocardial infraction, heart clots). Chronic Hepatitis C. Gallstones Sever Kidney failure (stage
* * ‫ﺍﻻﻟﺘﻬﺎﺏ ﺍﻟﻜﺒﺪﻯ ﺍﻟﻔﻴﺮﻭﺳﻰ ﺍﻟﻤﺰﻣﻦ‬.( ‫ﺍﻟﺮﺟﻔﺎﻥ ﺍﻟﻘﻠﺒﻰ ﻭﺟﻠﻄﺎﺕ ﺍﻟﻘﻠﺐ‬, ‫ﻓﺸﻞ ﻋﻀﻠﺔ ﺍﻟﻘﻠﺐ‬, ‫ﺣﺼﻮﺍﺕ ﺍﻟﻤﺮﺍﺭﺓ ﺍﻟﻘﻠﺐ‬, ‫ﺝ ﻭﺳﻰ‬
,‫ ﺍﻟﺘﺮﺷﻴﺢ ﺍﻟﻜﻠﻮﻯ ﺃﻗﻞ ﻣﻦ‬,‫ ﺍﻟﻔﺸﻞ ﺍﻟﻜﻠﻮﻯﺍﻟﺸﺪﻳﺪ )ﺍﻟﻤﺮﺣﻠﺔ ﺍﻟﺨﺎﻣﺴﺔ ﻣﻦ ﺍﻣﺮﺍﺽ ﺍﻟﻜﻠﻰ ﺍﻟﺘﻰ ﺗﺴﺘﺪﻋﻰ ﺍﻟﻐﺴﻴﻞ ﺍﻟﻜﻠﻮﻯ‬15
5 Requiring dialysis, clearance of less tha 15 ml/ minute*). Urinary tract ‫ﻣﺮﺽ‬, ‫ﺩﻗﻴﻘﺔ(ﺣﺼﻮﺍﺕ ﺍﻟﻤﺴﺎﻟﻚ ﺍﻟﺒﻮﻟﻴﺔﺃﻣﺮﺍﺽ ﺍﻟﻤﻨﺎﻋﺔ ﺍﻟﺘﺎﻟﻴﺔ )ﺍﻟﺬﺋﺒﺔ ﺍﻟﺤﻤﺮﺍﺀﻭﺍﻟﺘﻬﺎﺏ ﺍﻟﻤﻔﺎﺻﻞ ﺍﻟﺮﻭﻣﺎﺗﻴﺰﻣﻴﺔﻭ ﺍﻟﺼﺪﻓﻴﺔ‬/‫ﻣﻞ‬
stones, hernias. Autoimmune disease (lupus, rheumatoid arthritis, psoriasis, Crohn's disease, ‫ﺍﻟﺘﻬﺎﺏ ﺍﻟﻘﻮﻟﻮﻥ ﺍﻟﺘﻘﺮﺣﻰ‬, ‫ﻛﺮﻭﻧﺰ‬,
ulcerative colitis,multiple sclerosis, celiac disease) ‫ﺣﺴﺎﺳﻴﺔ ﺍﻟﻘﻤﺢ‬, ‫ﺍﻟﺘﺼﻠﺐ ﺍﻟﻠﻮﻳﺤﻰ‬

Have you been diagnosed with any of the following congenital disorder or
hereditary diseases limited to: Cerebral palsy, Sickle cell disorder, Thalassemia, ‫ﻫﻞ ﺗﻢ ﺗﺸﺨﻴﺼﻚ ﺑﺄﻱ ﻣﻦ ﺍﻷﻣﺮﺍﺽ ﺍﻟﻮﺭﺍﺛﻴﺔ ﺃﻭ ﺍﻟﺘﺸﻮﻫﺎﺕ ﺍﻟﺨﻠﻘﻴﺔ ﺍﻟﺘﺎﻟﻴﺔ ﻓﻘﻂ‬
hemophilia, metabolic diseases, Hydrocephalus, spinal muscle atrophy, genital ‫ ﺿﻤﻮﺭ‬،‫ ﺃﺳﺘﺴﻘﺎﺀ ﺍﻟﺮﺃﺱ‬،‫ ﺃﻣﺮﺍﺽ ﺍﻟﺘﻤﺜﻴﻞ ﺍﻟﻐﺬﺍﺋﻲ‬،‫ ﺍﻟﻬﻴﻤﻮﻓﻴﻠﻴﺎ‬،‫ ﺍﻟﺘﻼﺳﻴﻤﻴﺎ‬،‫ﺍﺿﻄﺮﺍﺏ ﺍﻟﺨﻼﻳﺎ ﺍﻟﻤﻨﺠﻠﻴﺔ‬, ‫ﺍﻟﺸﻠﻞ ﺍﻟﺪﻣﺎﻏﻰ‬
malformations, chromosomal abnormalities. Gaucher's disease, G6PD Deficiency, cystic
fibrosis, hemochromatosis, Wilson disease. Polycystic Kidney Disease.
* * ‫ ﻣﺮﺽ ﺍﻟﺘﻜﺴﺮﺍﻟﻔﻮﻟﻰ‬،‫ ﻣﺮﺽ ﻏﻮﺷﺮ‬،‫ ﺃﻣﺮﺍﺽ ﺍﻟﻜﺮﻭﻣﻮﺳﻮﻣﺎﺕ‬،‫ ﺗﺸﻮﻫﺎﺕ ﺍﻷﻋﻀﺎﺀ ﺍﻟﺘﻨﺎﺳﻠﻴﺔ‬،‫ﺍﻟﻌﻀﻼﺕ ﺍﻟﺸﻮﻛﻲ‬
‫ﺗﻜﻴﺲ‬,‫ﻣﺮﺽ ﻭﻳﻠﺴﻮﻥ‬, (‫ ﻣﺮﺽ ﺗﻜﺪﺱ ﺍﻟﺤﺪﻳﺪ )ﻫﻴﻤﻮﻛﺮﻭﻣﺎﺗﻮﺳﻴﺲ‬،‫( ﺍﻟﺘﻠﻴﻒ ﺍﻟﻜﻴﺴﻲ ﻟﻠﺮﺋﺔ‬G6PD)
‫ﺍﻟﻜﻠﻴﺘﻴﻦ ﺍﻟﺨﻠﻔﻰ ﺍﻟﻮﺭﺍﺋﻰ‬

Have you been diagnosed with any of following eye diseases limited to: ،‫ ﻣﻴﺎﺓ ﺯﺭﻗﺎﺀ‬،‫ ﻣﻴﺎﺓ ﺑﻴﻀﺎﺀ‬:‫ﻫﻞ ﺗﻢ ﺗﺸﺨﻴﺼﻚ ﺑﺄﻱ ﻣﻦ ﺃﻣﺮﺍﺽ ﺍﻟﻌﻴﻦ ﺍﻟﺘﺎﻟﻴﺔ ﻓﻘﻂ‬
Cataract, Glaucoma, Retinal diseases. * * ‫ﺃﻣﺮﺍﺽ ﺍﻟﺸﺒﻜﻴﺔ‬
Have you been diagnosed with any of the following bone diseases limited ‫ ﺍﻹﻧﺰﻻﻕ ﺍﻟﻐﻀﺮﻭﻓﻲ‬:‫ﻫﻞ ﺗﻢ ﺗﺸﺨﻴﺼﻚ ﺑﺄﻱ ﻣﻦ ﺃﻣﺮﺍﺽ ﺍﻟﻌﻈﺎﻡ ﺍﻟﺘﺎﻟﻴﺔ ﻓﻘﻂ‬
to:Vertebral disc prolapse (moderate or severe), Scoliosis (moderate or severe)**, or ligament
tears, osteoarthritis (moderate or severe )
* * ‫ﺗﻤﺰﻕ ﺍﻷﺭﺑﻄﺔ‬،‫ﺍﻟﺘﻬﺎﺏ ﺍﻟﻤﻔﺎﺻﻞ‬،‫ﺇﻧﺤﺮﺍﻑ ﺍﻟﻌﻤﻮﺩ ﺍﻟﻔﻘﺮﻱ‬,‫ﺍﻟﺪﻳﺴﻚ‬

Pregnant Female Only ‫ﻟﻸﻧﺜﻰ ﺍﻟﺤﺎﻣﻞ ﻓﻘﻂ‬

‫ﺣﻤﻞ ﺣﺎﻟﻲ ﺟﻨﻴﻦ ﻭﺍﺣﺪ‬
Current Single Pregnancy
* *
‫ﺣﻤﻞ ﺣﺎﻟﻲ ﻣﻊ ﻗﻴﺼﺮﻳﺔ ﺳﺎﺑﻘﺔ‬
Current Single Pregnancy with Previous CS Delivery
* *
‫ﺣﻤﻞ ﺣﺎﻟﻲ ﻣﺘﻌﺪﺩ ﺍﻷﺟﻨﺔ‬
Current Multiple Pregnancy
* *
Expected delivery date .. / .. / .... ‫ﺗﺎﺭﻳﺦ ﺍﻟﻮﻻﺩﺓ ﺍﻟﻤﺘﻮﻗﻊ‬
Employee and dependents details that need to be added ‫ﺑﻴﺎﻧﺎﺕ ﺍﻟﻤﻮﻇﻒ ﻭﺃﻓﺮﺍﺩ ﺍﻟﻌﺎﺋﻠﺔ ﺍﻟﻤﺮﺍﺩ ﺇﺿﺎﻓﺘﻬﻢ‬
In case of a yes answer above, please declare the case in the table below ‫ ﺍﻟﺮﺟﺎﺀ ﺫﻛﺮ ﺍﻟﺤﺎﻟﺔ ﻓﻲ ﺍﻟﺠﺪﻭﻝ ﺃﺩﻧﺎﻩ‬،‫ﻓﻲ ﺣﺎﻟﺔ ﺍﻹﺟﺎﺑﺔ ﺑﻨﻌﻢ ﺃﻋﻼﻩ‬
‫ﺇﺳﻢ ﻣﻘﺪﻡ ﺍﻟﺨﺪﻣﺔ‬ ‫ﺍﻟﺤﺎﻟﺔ‬ ‫ﺭﻗﻢ ﺍﻟﺠﻮﺍﻝ‬ ‫ﺍﻟﻄﻮﻝ‬ ‫ﺍﻟﻮﺯﻥ‬ ‫ﺭﻗﻢ ﺍﻟﻬﻮﻳﺔ‬ ‫ﺍﻟﻘﺮﺍﺑﺔ‬ ‫ﺍﻟﺠﻨﺲ‬ ‫ ﺃﻓﺮﺍﺩ ﺍﻟﻌﺎﺋﻠﺔ‬/ ‫ﺍﺳﻢ ﺍﻟﻤﻮﻇﻒ‬ ‫ﻡ‬
2121323402 Employee Male / ‫ ﺫﻛﺮ‬Yousuf Irshad - Abbasi 1
2
3
4
5
Undertakings : ‫ﺍﻹﻗﺮﺍﺭ ﻭﺍﻟﺘﻔﻮﻳﺾ‬
1- I hereby undertake that all the above information is correct and the acceptance of my ‫ﻭﺍﻟﻤﻌﻠﻮﻣﺎﺕ ﺍﻟﻤﺬﻛﻮﺭﺓ ﺃﻋﻼﻩ ﻛﺎﻣﻠﺔ ﻭﺻﺤﻴﺤﺔ ﻭﺑﻨﺎﺀ ﻋﻠﻴﻪ ﻓﺈﻥ ﻗﺒﻮﻝ ﺍﻟﻄﻠﺐ ﺳﻴﺘﻢ‬: ‫ ﺃﻗﺮ ﺃﻥ ﺍﻟﺒﻴﺎﻧﺎﺕ‬-1
enrollment will be on the basis of such information and that Malath Cooperative Insurance ‫ﻋﻠﻰ ﺃﺳﺎﺱ ﻫﺬﻩ ﺍﻟﺒﻴﺎﻧﺎﺕ ﻭﺃﻥ ﺷﺮﻛﺔ ﻣﻼﺫ ﻟﻠﺘﺄﻣﻴﻦ ﺍﻟﺘﻌﺎﻭﻧﻲ ﻟﻬﺎ ﺍﻟﺤﻖ ﻓﻲ ﺍﻻﺗﺼﺎﻝ ﺑﺎﻟﻤﺴﺘﺸﻔﻴﺎﺕ ﺍﻟﺘﻲ‬
Company has the right to contact the hospital(s) I deal with to collect any ‫ﺃﺗﻌﺎﻣﻞ ﻣﻌﻬﺎ ﻟﺘﺰﻭﻳﺪﻫﺎ ﺑﺄﻱ ﻣﻌﻠﻮﻣﺎﺕ ﻃﺒﻴﺔ ﻗﺪ ﺗﺤﺘﺎﺝ ﺇﻟﻴﻬﺎ ﻟﺘﻘﻴﻴﻢ ﺍﻟﻤﺨﺎﻃﺮ‬
medical information needed to assess the risk(s).

2- I agree that Malath Cooperative Insurance Company has the right to reject the ‫ ﺃﻭﺍﻓﻖ ﻋﻠﻰ ﺃﺣﻘﻴﺔ ﺷﺮﻛﺔ ﻣﻼﺫ ﻟﻠﺘﺄﻣﻴﻦ ﻓﻲ ﺭﻓﺾ ﺍﻟﻤﻄﺎﻟﺒﺔ ﺃﻭ ﺍﻟﺘﻐﻄﻴﺔ ﻛﻠﻴﺎ ﻋﻨﺪ ﻋﺪﻡ ﺍﻹﻓﺼﺎﺡ ﻋﻦ ﻭﺟﻮﺩ ﺃﻱ ﻣﻦ ﺍﻟﺤﺎﻻﺕ‬-2
coverage/claims in full in case of no declaration of any cases prior to the contractual date or ‫ﺍﻟﻤﺬﻛﻮﺭﺓ ﺃﻋﻼﻩ ﺍﻟﺘﻲ ﻧﺸﺄﺕ ﻗﺒﻞ ﺗﺎﺭﻳﺦ ﺍﻟﺘﻌﺎﻗﺪ ﺃﻭ ﻗﺒﻞ ﺗﺴﺠﻴﻞ ﺃﻭ ﺇﺿﺎﻓﺔ ﻋﻀﻮ ﺧﻼﻝ ﻓﺘﺮﺓ ﺳﺮﻳﺎﻥ ﺍﻟﻌﻘﺪ‬
before enrolling or adding a new member during the contract.

3- I hereby confirm reading and understanding all points presented in this form and I agree that ‫ ﺃﻗﺮﺑﺄﻧﻲ ﻗﺪ ﻗﺮﺃﺕ ﻭﻓﻬﻤﺖ ﺟﻤﻴﻊ ﻣﺎ ﺟﺎﺀ ﻓﻲ ﻫﺬﺍ ﺍﻟﻨﻤﻮﺫﺝ ﻛﻤﺎ ﺃﺗﻌﻬﺪ ﺑﺄﻥ ﻋﺪﻡ ﺇﺷﺎﺭﺗﻲ ﺃﻣﺎﻡ ﺃﻱ ﻣﻦ‬-3
not marking any case is understood as “Nothing requires declaration” and I sign on these ‫ﺍﻟﺤﺎﻻﺕ ﺍﻟﻤﺬﻛﻮﺭﺓ ﺃﻋﻼﻩ ﻳﻌﺘﺒﺮ ﺑﻤﺜﺎﺑﺔ ﻧﻔﻲ ﻭﺟﻮﺩ ﻣﺎﻳﺴﺘﺤﻖ ﺍﻹﻓﺼﺎﺡ ﻋﻨﻪ ﻭﻋﻠﻴﻪ ﺃﻭﻗﻊ‬
basis.
4- Failure to fill the weight and height information will result in refusal to cover
the cost of obesity surgery. ‫ ﻋﺪﻡ ﺗﻌﺒﺌﺔ ﺑﻴﺎﻧﺎﺕ ﺍﻟﻄﻮﻝ ﻭﺍﻟﻮﺯﻥ ﺳﻴﺆﺩﻱ ﺇﻟﻰ ﺭﻓﺾ ﺗﻐﻄﻴﺔ ﺗﻜﺎﻟﻴﻒ ﻋﻤﻠﻴﺔ ﺟﺮﺍﺣﺔ ﺍﻟﺴﻤﻨﺔ ﺍﻟﻤﻔﺮﻃﺔ‬-4

Entity's stamp ‫ﺧﺘﻢ ﺟﻬﺔ ﺍﻟﻌﻤﻞ‬ Insured Signature ‫ﺗﻮﻗﻴﻊ ﺍﻟﻤﻮﻇﻒ‬ Date ‫ﺍﻟﺘﺎﺭﻳﺦ‬
.. / .. / ....

New_Health_Insurance.rdf Page 27 of 39 V.20 13-DEC-2023 01:30 PM

 ‫ﻧﻤﻮﺫﺝ ﺍﻻﻓﺼﺎﺡ ﺍﻟﻄﺒﻲ ﺍﻟﻤﻮﺣﺪ‬
Unified Medical Declaration Form
Product Code: A-MLTH-2-C-08-014
Dear Insured: ‫ﻋﺰﻳﺰﻱ ﺍﻟﻤﺆﻣﻦ ﻟﻪ‬
Please Fill out the form correctly for the purpose of pricing and to ensured that you and your ‫ﻧﺄﻣﻞ ﻗﻴﺎﻣﻚ ﺑﺘﻌﺒﺌﺔ ﻫﺬﺍ ﺍﻟﻨﻤﻮﺫﺝ ﺑﺎﻟﺸﻜﻞ ﺍﻟﺼﺤﻴﺢ ﻟﻐﺮﺽ ﺍﻟﺘﺴﻌﻴﺮ ﻭﻟﻀﻤﺎﻥ ﺣﺼﻮﻟﻚ ﻭﺃﻓﺮﺍﺩ ﺃﺳﺮﺗﻚ ﻋﻠﻰ ﺧﺪﻣﺎﺕ‬
family receive health care services as required according to your unfied policy benefit ‫ﺍﻟﺮﻋﺎﻳﺔ ﺍﻟﺼﺤﻴﺔ ﺑﺎﻟﺸﻜﻞ ﺍﻟﻤﻄﻠﻮﺏ ﺣﺴﺐ ﻣﻨﺎﻓﻊ ﺍﻟﻮﺛﻴﻘﺔ ﺍﻟﻤﻮﺣﺪﺓ‬

Addition ‫ﺇﺿﺎﻓﺔ‬ New ‫ﺟﺪﻳﺪ‬ Type ‫ﻧﻮﻉ ﺍﻟﻄﻠﺐ‬

CR No 7011507360 ‫ﺍﻟﺴﺠﻞ ﺍﻟﺘﺠﺎﺭﻱ‬ Entity Name HADDAJ AL HIJAZ EST ‫ﺃﺳﻢ ﺍﻟﻤﻨﺸﺄﺓ‬
Mobile No 0564907682 ‫ﺭﻗﻢ ﺍﻟﺠﻮﺍﻝ‬ Sara Mohmed Azam ‫ﺍﺳﻢ ﺍﻟﻤﻮﻇﻒ‬
ID Number 2 1 1 9 7 1 4 2 4 0 ‫ﺭﻗﻢ ﺍﻟﻬﻮﻳﺔ‬
Gender Female / ‫ﺍﻟﺠﻨﺲ ﺃﻧﺜﻰ‬ Nationality India ‫ ﺍﻟﺠﻨﺴﻴﺔ‬Marital status Married R ‫ﻣﺘﺰﻭﺝ‬ Single * ‫ﺃﻋﺰﺏ‬ ‫ﺍﻟﺤﺎﻟﺔ ﺍﻻﺟﺘﻤﺎﻋﻴﺔ‬
Please declare any of the below cases by marking P under the word Yes ‫ ﻓﻲ ﺍﻟﻤﺮﺑﻊ ﺗﺤﺖ ﻛﻠﻤﺔ ﻧﻌﻢ‬P ‫ﻳﺮﺟﻰ ﺍﻹﻓﺼﺎﺡ ﻋﻦ ﻭﺟﻮﺩ ﺃﻱ ﻣﻦ ﺍﻟﺤﺎﻻﺕ ﺍﺩﻧﺎﻩ ﺑﻮﺿﻊ ﺇﺷﺎﺭﺓ‬
"Below Undeclared Medical Case May Not Be Covered" No / ‫ﻻ‬ Yes / ‫ﻧﻌـﻢ‬ "‫"ﻟﻦ ﺗﺘﻢ ﺍﻟﺘﻐﻄﻴﺔ ﺍﻟﺘﺄﻣﻴﻨﻴﺔ ﻟﻠﺤﺎﻻﺕ ﺃﺩﻧﺎﻩ ﻓﻰ ﺣﺎﻝ ﻋﺪﻡ ﺍﻹﻓﺼﺎﺡ ﻋﻨﻬﺎ‬
Any hospital admission during last 12 months. ‫ ﺷﻬﺮ‬12 ‫ﻫﻞ ﺗﻢ ﺍﻟﺘﻨﻮﻳﻢ ﺑﺎﻟﻤﺴﺘﺸﻔﻰ ﺧﻼﻝ ﺃﺧﺮ‬
"Admission: registering as an admitted patient at the hospital until the following morning "
* * " ‫ ﺗﺴﺠﻴﻞ ﺍﻟﺸﺨﺺ ﺍﻟﻤﺆﻣﻦ ﻟﻪ ﻛﻤﺮﻳﺾ ﻣﻨﻮﻡ ﻓﻲ ﺍﻟﻤﺴﺘﺸﻔﻰ ﺣﺘﻰ ﺻﺒﺎﺡ ﺍﻟﻴﻮﻡ ﺍﻟﺘﺎﻟﻲ‬: ‫" ﺍﻟﺘﻨﻮﻳﻢ‬

Have you been diagnosed with any of the following chronic disease limited ‫ﻫﻞ ﺗﻢ ﺗﺸﺨﻴﺼﻚ ﺑﺄﻯ ﻣﻦ ﺍﻷﻣﺮﺍﺽ ﺍﻟﺘﺎﻟﻴﺔ ﻓﻘﻂ‬
to:Autism, listed Benign Tumor (Breast tumors, fibroid uterus, benign prostatic hyperplasia, ‫ﺃﻭﺭﺍﻡ ﺃﻭ‬,‫ﺗﻀﺨﻢ ﺍﻟﺒﺮﻭﺳﺘﺎﺗﺎ ﺍﻟﺤﻤﻴﺪ‬,‫ ﺃﻭﺭﺍﻡ ﺍﻟﺮﺣﻢ ﺍﻟﻠﻴﻔﻰ‬, ‫ﺍﻻﻭﺭﺍﻡ ﺍﻟﺤﻤﻴﺪﺓ ﺍﻟﺘﺎﻟﻴﺔ )ﺃﻭﺭﺍﻡ ﺍﻟﺜﺪﻯ‬,‫ﺍﻷﻭﺭﺍﻡ ﺍﻟﺴﺮﻃﺎﻧﻴﺔ‬,‫ﺍﻟﺘﻮﺣﺪ‬
thyroid goiter and parathyroid glands, live tumors, colon tumors). Malignant tumors, listed ‫ﺃﻣﺮﺍﺽ ﺍﻟﻘﻠﺐ ﺍﻟﺘﺎﻟﻴﺔ)ﺃﻣﺮﺍﺽ ﺷﺮﺍﻳﻴﻦ ﻭﺻﻤﺎﻣﺎﺕ ﺗﻀﺨﻢ ﺍﻟﻐﺪﺓ ﺍﻟﺪﺭﻗﻴﺔ‬, (‫ﺃﻭﺭﺍﻡ ﺍﻟﻘﻮﻟﻮﻥ‬, ‫ﻭﺃﻭﺭﺍﻡ ﺍﻻﻟﻜﺒﺪ‬,‫ﻭ ﺍﻟﺠﺎﺭ ﺍﻟﺪﺭﻗﻴﺔ‬
Cardiac diseases coronary and valve heart diseases, heart failure, cardiac fibrillation
myocardial infraction, heart clots). Chronic Hepatitis C. Gallstones Sever Kidney failure (stage
* * ‫ﺍﻻﻟﺘﻬﺎﺏ ﺍﻟﻜﺒﺪﻯ ﺍﻟﻔﻴﺮﻭﺳﻰ ﺍﻟﻤﺰﻣﻦ‬.( ‫ﺍﻟﺮﺟﻔﺎﻥ ﺍﻟﻘﻠﺒﻰ ﻭﺟﻠﻄﺎﺕ ﺍﻟﻘﻠﺐ‬, ‫ﻓﺸﻞ ﻋﻀﻠﺔ ﺍﻟﻘﻠﺐ‬, ‫ﺣﺼﻮﺍﺕ ﺍﻟﻤﺮﺍﺭﺓ ﺍﻟﻘﻠﺐ‬, ‫ﺝ ﻭﺳﻰ‬
,‫ ﺍﻟﺘﺮﺷﻴﺢ ﺍﻟﻜﻠﻮﻯ ﺃﻗﻞ ﻣﻦ‬,‫ ﺍﻟﻔﺸﻞ ﺍﻟﻜﻠﻮﻯﺍﻟﺸﺪﻳﺪ )ﺍﻟﻤﺮﺣﻠﺔ ﺍﻟﺨﺎﻣﺴﺔ ﻣﻦ ﺍﻣﺮﺍﺽ ﺍﻟﻜﻠﻰ ﺍﻟﺘﻰ ﺗﺴﺘﺪﻋﻰ ﺍﻟﻐﺴﻴﻞ ﺍﻟﻜﻠﻮﻯ‬15
5 Requiring dialysis, clearance of less tha 15 ml/ minute*). Urinary tract ‫ﻣﺮﺽ‬, ‫ﺩﻗﻴﻘﺔ(ﺣﺼﻮﺍﺕ ﺍﻟﻤﺴﺎﻟﻚ ﺍﻟﺒﻮﻟﻴﺔﺃﻣﺮﺍﺽ ﺍﻟﻤﻨﺎﻋﺔ ﺍﻟﺘﺎﻟﻴﺔ )ﺍﻟﺬﺋﺒﺔ ﺍﻟﺤﻤﺮﺍﺀﻭﺍﻟﺘﻬﺎﺏ ﺍﻟﻤﻔﺎﺻﻞ ﺍﻟﺮﻭﻣﺎﺗﻴﺰﻣﻴﺔﻭ ﺍﻟﺼﺪﻓﻴﺔ‬/‫ﻣﻞ‬
stones, hernias. Autoimmune disease (lupus, rheumatoid arthritis, psoriasis, Crohn's disease, ‫ﺍﻟﺘﻬﺎﺏ ﺍﻟﻘﻮﻟﻮﻥ ﺍﻟﺘﻘﺮﺣﻰ‬, ‫ﻛﺮﻭﻧﺰ‬,
ulcerative colitis,multiple sclerosis, celiac disease) ‫ﺣﺴﺎﺳﻴﺔ ﺍﻟﻘﻤﺢ‬, ‫ﺍﻟﺘﺼﻠﺐ ﺍﻟﻠﻮﻳﺤﻰ‬

Have you been diagnosed with any of the following congenital disorder or
hereditary diseases limited to: Cerebral palsy, Sickle cell disorder, Thalassemia, ‫ﻫﻞ ﺗﻢ ﺗﺸﺨﻴﺼﻚ ﺑﺄﻱ ﻣﻦ ﺍﻷﻣﺮﺍﺽ ﺍﻟﻮﺭﺍﺛﻴﺔ ﺃﻭ ﺍﻟﺘﺸﻮﻫﺎﺕ ﺍﻟﺨﻠﻘﻴﺔ ﺍﻟﺘﺎﻟﻴﺔ ﻓﻘﻂ‬
hemophilia, metabolic diseases, Hydrocephalus, spinal muscle atrophy, genital ‫ ﺿﻤﻮﺭ‬،‫ ﺃﺳﺘﺴﻘﺎﺀ ﺍﻟﺮﺃﺱ‬،‫ ﺃﻣﺮﺍﺽ ﺍﻟﺘﻤﺜﻴﻞ ﺍﻟﻐﺬﺍﺋﻲ‬،‫ ﺍﻟﻬﻴﻤﻮﻓﻴﻠﻴﺎ‬،‫ ﺍﻟﺘﻼﺳﻴﻤﻴﺎ‬،‫ﺍﺿﻄﺮﺍﺏ ﺍﻟﺨﻼﻳﺎ ﺍﻟﻤﻨﺠﻠﻴﺔ‬, ‫ﺍﻟﺸﻠﻞ ﺍﻟﺪﻣﺎﻏﻰ‬
malformations, chromosomal abnormalities. Gaucher's disease, G6PD Deficiency, cystic
fibrosis, hemochromatosis, Wilson disease. Polycystic Kidney Disease.
* * ‫ ﻣﺮﺽ ﺍﻟﺘﻜﺴﺮﺍﻟﻔﻮﻟﻰ‬،‫ ﻣﺮﺽ ﻏﻮﺷﺮ‬،‫ ﺃﻣﺮﺍﺽ ﺍﻟﻜﺮﻭﻣﻮﺳﻮﻣﺎﺕ‬،‫ ﺗﺸﻮﻫﺎﺕ ﺍﻷﻋﻀﺎﺀ ﺍﻟﺘﻨﺎﺳﻠﻴﺔ‬،‫ﺍﻟﻌﻀﻼﺕ ﺍﻟﺸﻮﻛﻲ‬
‫ﺗﻜﻴﺲ‬,‫ﻣﺮﺽ ﻭﻳﻠﺴﻮﻥ‬, (‫ ﻣﺮﺽ ﺗﻜﺪﺱ ﺍﻟﺤﺪﻳﺪ )ﻫﻴﻤﻮﻛﺮﻭﻣﺎﺗﻮﺳﻴﺲ‬،‫( ﺍﻟﺘﻠﻴﻒ ﺍﻟﻜﻴﺴﻲ ﻟﻠﺮﺋﺔ‬G6PD)
‫ﺍﻟﻜﻠﻴﺘﻴﻦ ﺍﻟﺨﻠﻔﻰ ﺍﻟﻮﺭﺍﺋﻰ‬

Have you been diagnosed with any of following eye diseases limited to: ،‫ ﻣﻴﺎﺓ ﺯﺭﻗﺎﺀ‬،‫ ﻣﻴﺎﺓ ﺑﻴﻀﺎﺀ‬:‫ﻫﻞ ﺗﻢ ﺗﺸﺨﻴﺼﻚ ﺑﺄﻱ ﻣﻦ ﺃﻣﺮﺍﺽ ﺍﻟﻌﻴﻦ ﺍﻟﺘﺎﻟﻴﺔ ﻓﻘﻂ‬
Cataract, Glaucoma, Retinal diseases. * * ‫ﺃﻣﺮﺍﺽ ﺍﻟﺸﺒﻜﻴﺔ‬
Have you been diagnosed with any of the following bone diseases limited ‫ ﺍﻹﻧﺰﻻﻕ ﺍﻟﻐﻀﺮﻭﻓﻲ‬:‫ﻫﻞ ﺗﻢ ﺗﺸﺨﻴﺼﻚ ﺑﺄﻱ ﻣﻦ ﺃﻣﺮﺍﺽ ﺍﻟﻌﻈﺎﻡ ﺍﻟﺘﺎﻟﻴﺔ ﻓﻘﻂ‬
to:Vertebral disc prolapse (moderate or severe), Scoliosis (moderate or severe)**, or ligament
tears, osteoarthritis (moderate or severe )
* * ‫ﺗﻤﺰﻕ ﺍﻷﺭﺑﻄﺔ‬،‫ﺍﻟﺘﻬﺎﺏ ﺍﻟﻤﻔﺎﺻﻞ‬،‫ﺇﻧﺤﺮﺍﻑ ﺍﻟﻌﻤﻮﺩ ﺍﻟﻔﻘﺮﻱ‬,‫ﺍﻟﺪﻳﺴﻚ‬

Pregnant Female Only ‫ﻟﻸﻧﺜﻰ ﺍﻟﺤﺎﻣﻞ ﻓﻘﻂ‬

‫ﺣﻤﻞ ﺣﺎﻟﻲ ﺟﻨﻴﻦ ﻭﺍﺣﺪ‬
Current Single Pregnancy
* *
‫ﺣﻤﻞ ﺣﺎﻟﻲ ﻣﻊ ﻗﻴﺼﺮﻳﺔ ﺳﺎﺑﻘﺔ‬
Current Single Pregnancy with Previous CS Delivery
* *
‫ﺣﻤﻞ ﺣﺎﻟﻲ ﻣﺘﻌﺪﺩ ﺍﻷﺟﻨﺔ‬
Current Multiple Pregnancy
* *
Expected delivery date .. / .. / .... ‫ﺗﺎﺭﻳﺦ ﺍﻟﻮﻻﺩﺓ ﺍﻟﻤﺘﻮﻗﻊ‬
Employee and dependents details that need to be added ‫ﺑﻴﺎﻧﺎﺕ ﺍﻟﻤﻮﻇﻒ ﻭﺃﻓﺮﺍﺩ ﺍﻟﻌﺎﺋﻠﺔ ﺍﻟﻤﺮﺍﺩ ﺇﺿﺎﻓﺘﻬﻢ‬
In case of a yes answer above, please declare the case in the table below ‫ ﺍﻟﺮﺟﺎﺀ ﺫﻛﺮ ﺍﻟﺤﺎﻟﺔ ﻓﻲ ﺍﻟﺠﺪﻭﻝ ﺃﺩﻧﺎﻩ‬،‫ﻓﻲ ﺣﺎﻟﺔ ﺍﻹﺟﺎﺑﺔ ﺑﻨﻌﻢ ﺃﻋﻼﻩ‬
‫ﺇﺳﻢ ﻣﻘﺪﻡ ﺍﻟﺨﺪﻣﺔ‬ ‫ﺍﻟﺤﺎﻟﺔ‬ ‫ﺭﻗﻢ ﺍﻟﺠﻮﺍﻝ‬ ‫ﺍﻟﻄﻮﻝ‬ ‫ﺍﻟﻮﺯﻥ‬ ‫ﺭﻗﻢ ﺍﻟﻬﻮﻳﺔ‬ ‫ﺍﻟﻘﺮﺍﺑﺔ‬ ‫ﺍﻟﺠﻨﺲ‬ ‫ ﺃﻓﺮﺍﺩ ﺍﻟﻌﺎﺋﻠﺔ‬/ ‫ﺍﺳﻢ ﺍﻟﻤﻮﻇﻒ‬ ‫ﻡ‬
2119714240 Spouse Female / ‫ ﺃﻧﺜﻰ‬Sara Mohmed Azam 1
2
3
4
5
Undertakings : ‫ﺍﻹﻗﺮﺍﺭ ﻭﺍﻟﺘﻔﻮﻳﺾ‬
1- I hereby undertake that all the above information is correct and the acceptance of my ‫ﻭﺍﻟﻤﻌﻠﻮﻣﺎﺕ ﺍﻟﻤﺬﻛﻮﺭﺓ ﺃﻋﻼﻩ ﻛﺎﻣﻠﺔ ﻭﺻﺤﻴﺤﺔ ﻭﺑﻨﺎﺀ ﻋﻠﻴﻪ ﻓﺈﻥ ﻗﺒﻮﻝ ﺍﻟﻄﻠﺐ ﺳﻴﺘﻢ‬: ‫ ﺃﻗﺮ ﺃﻥ ﺍﻟﺒﻴﺎﻧﺎﺕ‬-1
enrollment will be on the basis of such information and that Malath Cooperative Insurance ‫ﻋﻠﻰ ﺃﺳﺎﺱ ﻫﺬﻩ ﺍﻟﺒﻴﺎﻧﺎﺕ ﻭﺃﻥ ﺷﺮﻛﺔ ﻣﻼﺫ ﻟﻠﺘﺄﻣﻴﻦ ﺍﻟﺘﻌﺎﻭﻧﻲ ﻟﻬﺎ ﺍﻟﺤﻖ ﻓﻲ ﺍﻻﺗﺼﺎﻝ ﺑﺎﻟﻤﺴﺘﺸﻔﻴﺎﺕ ﺍﻟﺘﻲ‬
Company has the right to contact the hospital(s) I deal with to collect any ‫ﺃﺗﻌﺎﻣﻞ ﻣﻌﻬﺎ ﻟﺘﺰﻭﻳﺪﻫﺎ ﺑﺄﻱ ﻣﻌﻠﻮﻣﺎﺕ ﻃﺒﻴﺔ ﻗﺪ ﺗﺤﺘﺎﺝ ﺇﻟﻴﻬﺎ ﻟﺘﻘﻴﻴﻢ ﺍﻟﻤﺨﺎﻃﺮ‬
medical information needed to assess the risk(s).

2- I agree that Malath Cooperative Insurance Company has the right to reject the ‫ ﺃﻭﺍﻓﻖ ﻋﻠﻰ ﺃﺣﻘﻴﺔ ﺷﺮﻛﺔ ﻣﻼﺫ ﻟﻠﺘﺄﻣﻴﻦ ﻓﻲ ﺭﻓﺾ ﺍﻟﻤﻄﺎﻟﺒﺔ ﺃﻭ ﺍﻟﺘﻐﻄﻴﺔ ﻛﻠﻴﺎ ﻋﻨﺪ ﻋﺪﻡ ﺍﻹﻓﺼﺎﺡ ﻋﻦ ﻭﺟﻮﺩ ﺃﻱ ﻣﻦ ﺍﻟﺤﺎﻻﺕ‬-2
coverage/claims in full in case of no declaration of any cases prior to the contractual date or ‫ﺍﻟﻤﺬﻛﻮﺭﺓ ﺃﻋﻼﻩ ﺍﻟﺘﻲ ﻧﺸﺄﺕ ﻗﺒﻞ ﺗﺎﺭﻳﺦ ﺍﻟﺘﻌﺎﻗﺪ ﺃﻭ ﻗﺒﻞ ﺗﺴﺠﻴﻞ ﺃﻭ ﺇﺿﺎﻓﺔ ﻋﻀﻮ ﺧﻼﻝ ﻓﺘﺮﺓ ﺳﺮﻳﺎﻥ ﺍﻟﻌﻘﺪ‬
before enrolling or adding a new member during the contract.

3- I hereby confirm reading and understanding all points presented in this form and I agree that ‫ ﺃﻗﺮﺑﺄﻧﻲ ﻗﺪ ﻗﺮﺃﺕ ﻭﻓﻬﻤﺖ ﺟﻤﻴﻊ ﻣﺎ ﺟﺎﺀ ﻓﻲ ﻫﺬﺍ ﺍﻟﻨﻤﻮﺫﺝ ﻛﻤﺎ ﺃﺗﻌﻬﺪ ﺑﺄﻥ ﻋﺪﻡ ﺇﺷﺎﺭﺗﻲ ﺃﻣﺎﻡ ﺃﻱ ﻣﻦ‬-3
not marking any case is understood as “Nothing requires declaration” and I sign on these ‫ﺍﻟﺤﺎﻻﺕ ﺍﻟﻤﺬﻛﻮﺭﺓ ﺃﻋﻼﻩ ﻳﻌﺘﺒﺮ ﺑﻤﺜﺎﺑﺔ ﻧﻔﻲ ﻭﺟﻮﺩ ﻣﺎﻳﺴﺘﺤﻖ ﺍﻹﻓﺼﺎﺡ ﻋﻨﻪ ﻭﻋﻠﻴﻪ ﺃﻭﻗﻊ‬
basis.
4- Failure to fill the weight and height information will result in refusal to cover
the cost of obesity surgery. ‫ ﻋﺪﻡ ﺗﻌﺒﺌﺔ ﺑﻴﺎﻧﺎﺕ ﺍﻟﻄﻮﻝ ﻭﺍﻟﻮﺯﻥ ﺳﻴﺆﺩﻱ ﺇﻟﻰ ﺭﻓﺾ ﺗﻐﻄﻴﺔ ﺗﻜﺎﻟﻴﻒ ﻋﻤﻠﻴﺔ ﺟﺮﺍﺣﺔ ﺍﻟﺴﻤﻨﺔ ﺍﻟﻤﻔﺮﻃﺔ‬-4

Entity's stamp ‫ﺧﺘﻢ ﺟﻬﺔ ﺍﻟﻌﻤﻞ‬ Insured Signature ‫ﺗﻮﻗﻴﻊ ﺍﻟﻤﻮﻇﻒ‬ Date ‫ﺍﻟﺘﺎﺭﻳﺦ‬
.. / .. / ....

New_Health_Insurance.rdf Page 28 of 39 V.20 13-DEC-2023 01:30 PM

 ‫ﻧﻤﻮﺫﺝ ﺍﻻﻓﺼﺎﺡ ﺍﻟﻄﺒﻲ ﺍﻟﻤﻮﺣﺪ‬
Unified Medical Declaration Form
Product Code: A-MLTH-2-C-08-014
Dear Insured: ‫ﻋﺰﻳﺰﻱ ﺍﻟﻤﺆﻣﻦ ﻟﻪ‬
Please Fill out the form correctly for the purpose of pricing and to ensured that you and your ‫ﻧﺄﻣﻞ ﻗﻴﺎﻣﻚ ﺑﺘﻌﺒﺌﺔ ﻫﺬﺍ ﺍﻟﻨﻤﻮﺫﺝ ﺑﺎﻟﺸﻜﻞ ﺍﻟﺼﺤﻴﺢ ﻟﻐﺮﺽ ﺍﻟﺘﺴﻌﻴﺮ ﻭﻟﻀﻤﺎﻥ ﺣﺼﻮﻟﻚ ﻭﺃﻓﺮﺍﺩ ﺃﺳﺮﺗﻚ ﻋﻠﻰ ﺧﺪﻣﺎﺕ‬
family receive health care services as required according to your unfied policy benefit ‫ﺍﻟﺮﻋﺎﻳﺔ ﺍﻟﺼﺤﻴﺔ ﺑﺎﻟﺸﻜﻞ ﺍﻟﻤﻄﻠﻮﺏ ﺣﺴﺐ ﻣﻨﺎﻓﻊ ﺍﻟﻮﺛﻴﻘﺔ ﺍﻟﻤﻮﺣﺪﺓ‬

Addition ‫ﺇﺿﺎﻓﺔ‬ New ‫ﺟﺪﻳﺪ‬ Type ‫ﻧﻮﻉ ﺍﻟﻄﻠﺐ‬

CR No 7011507360 ‫ﺍﻟﺴﺠﻞ ﺍﻟﺘﺠﺎﺭﻱ‬ Entity Name HADDAJ AL HIJAZ EST ‫ﺃﺳﻢ ﺍﻟﻤﻨﺸﺄﺓ‬
Mobile No 0501625954 ‫ﺭﻗﻢ ﺍﻟﺠﻮﺍﻝ‬ Aklas Ahmed Nooruddin ‫ﺍﺳﻢ ﺍﻟﻤﻮﻇﻒ‬
ID Number 2 1 7 6 1 4 3 2 5 9 ‫ﺭﻗﻢ ﺍﻟﻬﻮﻳﺔ‬
Male / ‫ﺫﻛﺮ‬ Bangladesh
Gender ‫ ﺍﻟﺠﻨﺲ‬Nationality ‫ ﺍﻟﺠﻨﺴﻴﺔ‬Marital status Married R ‫ﻣﺘﺰﻭﺝ‬ Single * ‫ﺃﻋﺰﺏ‬ ‫ﺍﻟﺤﺎﻟﺔ ﺍﻻﺟﺘﻤﺎﻋﻴﺔ‬
Please declare any of the below cases by marking P under the word Yes ‫ ﻓﻲ ﺍﻟﻤﺮﺑﻊ ﺗﺤﺖ ﻛﻠﻤﺔ ﻧﻌﻢ‬P ‫ﻳﺮﺟﻰ ﺍﻹﻓﺼﺎﺡ ﻋﻦ ﻭﺟﻮﺩ ﺃﻱ ﻣﻦ ﺍﻟﺤﺎﻻﺕ ﺍﺩﻧﺎﻩ ﺑﻮﺿﻊ ﺇﺷﺎﺭﺓ‬
"Below Undeclared Medical Case May Not Be Covered" No / ‫ﻻ‬ Yes / ‫ﻧﻌـﻢ‬ "‫"ﻟﻦ ﺗﺘﻢ ﺍﻟﺘﻐﻄﻴﺔ ﺍﻟﺘﺄﻣﻴﻨﻴﺔ ﻟﻠﺤﺎﻻﺕ ﺃﺩﻧﺎﻩ ﻓﻰ ﺣﺎﻝ ﻋﺪﻡ ﺍﻹﻓﺼﺎﺡ ﻋﻨﻬﺎ‬
Any hospital admission during last 12 months. ‫ ﺷﻬﺮ‬12 ‫ﻫﻞ ﺗﻢ ﺍﻟﺘﻨﻮﻳﻢ ﺑﺎﻟﻤﺴﺘﺸﻔﻰ ﺧﻼﻝ ﺃﺧﺮ‬
"Admission: registering as an admitted patient at the hospital until the following morning "
* * " ‫ ﺗﺴﺠﻴﻞ ﺍﻟﺸﺨﺺ ﺍﻟﻤﺆﻣﻦ ﻟﻪ ﻛﻤﺮﻳﺾ ﻣﻨﻮﻡ ﻓﻲ ﺍﻟﻤﺴﺘﺸﻔﻰ ﺣﺘﻰ ﺻﺒﺎﺡ ﺍﻟﻴﻮﻡ ﺍﻟﺘﺎﻟﻲ‬: ‫" ﺍﻟﺘﻨﻮﻳﻢ‬

Have you been diagnosed with any of the following chronic disease limited ‫ﻫﻞ ﺗﻢ ﺗﺸﺨﻴﺼﻚ ﺑﺄﻯ ﻣﻦ ﺍﻷﻣﺮﺍﺽ ﺍﻟﺘﺎﻟﻴﺔ ﻓﻘﻂ‬
to:Autism, listed Benign Tumor (Breast tumors, fibroid uterus, benign prostatic hyperplasia, ‫ﺃﻭﺭﺍﻡ ﺃﻭ‬,‫ﺗﻀﺨﻢ ﺍﻟﺒﺮﻭﺳﺘﺎﺗﺎ ﺍﻟﺤﻤﻴﺪ‬,‫ ﺃﻭﺭﺍﻡ ﺍﻟﺮﺣﻢ ﺍﻟﻠﻴﻔﻰ‬, ‫ﺍﻻﻭﺭﺍﻡ ﺍﻟﺤﻤﻴﺪﺓ ﺍﻟﺘﺎﻟﻴﺔ )ﺃﻭﺭﺍﻡ ﺍﻟﺜﺪﻯ‬,‫ﺍﻷﻭﺭﺍﻡ ﺍﻟﺴﺮﻃﺎﻧﻴﺔ‬,‫ﺍﻟﺘﻮﺣﺪ‬
thyroid goiter and parathyroid glands, live tumors, colon tumors). Malignant tumors, listed ‫ﺃﻣﺮﺍﺽ ﺍﻟﻘﻠﺐ ﺍﻟﺘﺎﻟﻴﺔ)ﺃﻣﺮﺍﺽ ﺷﺮﺍﻳﻴﻦ ﻭﺻﻤﺎﻣﺎﺕ ﺗﻀﺨﻢ ﺍﻟﻐﺪﺓ ﺍﻟﺪﺭﻗﻴﺔ‬, (‫ﺃﻭﺭﺍﻡ ﺍﻟﻘﻮﻟﻮﻥ‬, ‫ﻭﺃﻭﺭﺍﻡ ﺍﻻﻟﻜﺒﺪ‬,‫ﻭ ﺍﻟﺠﺎﺭ ﺍﻟﺪﺭﻗﻴﺔ‬
Cardiac diseases coronary and valve heart diseases, heart failure, cardiac fibrillation
myocardial infraction, heart clots). Chronic Hepatitis C. Gallstones Sever Kidney failure (stage
* * ‫ﺍﻻﻟﺘﻬﺎﺏ ﺍﻟﻜﺒﺪﻯ ﺍﻟﻔﻴﺮﻭﺳﻰ ﺍﻟﻤﺰﻣﻦ‬.( ‫ﺍﻟﺮﺟﻔﺎﻥ ﺍﻟﻘﻠﺒﻰ ﻭﺟﻠﻄﺎﺕ ﺍﻟﻘﻠﺐ‬, ‫ﻓﺸﻞ ﻋﻀﻠﺔ ﺍﻟﻘﻠﺐ‬, ‫ﺣﺼﻮﺍﺕ ﺍﻟﻤﺮﺍﺭﺓ ﺍﻟﻘﻠﺐ‬, ‫ﺝ ﻭﺳﻰ‬
,‫ ﺍﻟﺘﺮﺷﻴﺢ ﺍﻟﻜﻠﻮﻯ ﺃﻗﻞ ﻣﻦ‬,‫ ﺍﻟﻔﺸﻞ ﺍﻟﻜﻠﻮﻯﺍﻟﺸﺪﻳﺪ )ﺍﻟﻤﺮﺣﻠﺔ ﺍﻟﺨﺎﻣﺴﺔ ﻣﻦ ﺍﻣﺮﺍﺽ ﺍﻟﻜﻠﻰ ﺍﻟﺘﻰ ﺗﺴﺘﺪﻋﻰ ﺍﻟﻐﺴﻴﻞ ﺍﻟﻜﻠﻮﻯ‬15
5 Requiring dialysis, clearance of less tha 15 ml/ minute*). Urinary tract ‫ﻣﺮﺽ‬, ‫ﺩﻗﻴﻘﺔ(ﺣﺼﻮﺍﺕ ﺍﻟﻤﺴﺎﻟﻚ ﺍﻟﺒﻮﻟﻴﺔﺃﻣﺮﺍﺽ ﺍﻟﻤﻨﺎﻋﺔ ﺍﻟﺘﺎﻟﻴﺔ )ﺍﻟﺬﺋﺒﺔ ﺍﻟﺤﻤﺮﺍﺀﻭﺍﻟﺘﻬﺎﺏ ﺍﻟﻤﻔﺎﺻﻞ ﺍﻟﺮﻭﻣﺎﺗﻴﺰﻣﻴﺔﻭ ﺍﻟﺼﺪﻓﻴﺔ‬/‫ﻣﻞ‬
stones, hernias. Autoimmune disease (lupus, rheumatoid arthritis, psoriasis, Crohn's disease, ‫ﺍﻟﺘﻬﺎﺏ ﺍﻟﻘﻮﻟﻮﻥ ﺍﻟﺘﻘﺮﺣﻰ‬, ‫ﻛﺮﻭﻧﺰ‬,
ulcerative colitis,multiple sclerosis, celiac disease) ‫ﺣﺴﺎﺳﻴﺔ ﺍﻟﻘﻤﺢ‬, ‫ﺍﻟﺘﺼﻠﺐ ﺍﻟﻠﻮﻳﺤﻰ‬

Have you been diagnosed with any of the following congenital disorder or
hereditary diseases limited to: Cerebral palsy, Sickle cell disorder, Thalassemia, ‫ﻫﻞ ﺗﻢ ﺗﺸﺨﻴﺼﻚ ﺑﺄﻱ ﻣﻦ ﺍﻷﻣﺮﺍﺽ ﺍﻟﻮﺭﺍﺛﻴﺔ ﺃﻭ ﺍﻟﺘﺸﻮﻫﺎﺕ ﺍﻟﺨﻠﻘﻴﺔ ﺍﻟﺘﺎﻟﻴﺔ ﻓﻘﻂ‬
hemophilia, metabolic diseases, Hydrocephalus, spinal muscle atrophy, genital ‫ ﺿﻤﻮﺭ‬،‫ ﺃﺳﺘﺴﻘﺎﺀ ﺍﻟﺮﺃﺱ‬،‫ ﺃﻣﺮﺍﺽ ﺍﻟﺘﻤﺜﻴﻞ ﺍﻟﻐﺬﺍﺋﻲ‬،‫ ﺍﻟﻬﻴﻤﻮﻓﻴﻠﻴﺎ‬،‫ ﺍﻟﺘﻼﺳﻴﻤﻴﺎ‬،‫ﺍﺿﻄﺮﺍﺏ ﺍﻟﺨﻼﻳﺎ ﺍﻟﻤﻨﺠﻠﻴﺔ‬, ‫ﺍﻟﺸﻠﻞ ﺍﻟﺪﻣﺎﻏﻰ‬
malformations, chromosomal abnormalities. Gaucher's disease, G6PD Deficiency, cystic
fibrosis, hemochromatosis, Wilson disease. Polycystic Kidney Disease.
* * ‫ ﻣﺮﺽ ﺍﻟﺘﻜﺴﺮﺍﻟﻔﻮﻟﻰ‬،‫ ﻣﺮﺽ ﻏﻮﺷﺮ‬،‫ ﺃﻣﺮﺍﺽ ﺍﻟﻜﺮﻭﻣﻮﺳﻮﻣﺎﺕ‬،‫ ﺗﺸﻮﻫﺎﺕ ﺍﻷﻋﻀﺎﺀ ﺍﻟﺘﻨﺎﺳﻠﻴﺔ‬،‫ﺍﻟﻌﻀﻼﺕ ﺍﻟﺸﻮﻛﻲ‬
‫ﺗﻜﻴﺲ‬,‫ﻣﺮﺽ ﻭﻳﻠﺴﻮﻥ‬, (‫ ﻣﺮﺽ ﺗﻜﺪﺱ ﺍﻟﺤﺪﻳﺪ )ﻫﻴﻤﻮﻛﺮﻭﻣﺎﺗﻮﺳﻴﺲ‬،‫( ﺍﻟﺘﻠﻴﻒ ﺍﻟﻜﻴﺴﻲ ﻟﻠﺮﺋﺔ‬G6PD)
‫ﺍﻟﻜﻠﻴﺘﻴﻦ ﺍﻟﺨﻠﻔﻰ ﺍﻟﻮﺭﺍﺋﻰ‬

Have you been diagnosed with any of following eye diseases limited to: ،‫ ﻣﻴﺎﺓ ﺯﺭﻗﺎﺀ‬،‫ ﻣﻴﺎﺓ ﺑﻴﻀﺎﺀ‬:‫ﻫﻞ ﺗﻢ ﺗﺸﺨﻴﺼﻚ ﺑﺄﻱ ﻣﻦ ﺃﻣﺮﺍﺽ ﺍﻟﻌﻴﻦ ﺍﻟﺘﺎﻟﻴﺔ ﻓﻘﻂ‬
Cataract, Glaucoma, Retinal diseases. * * ‫ﺃﻣﺮﺍﺽ ﺍﻟﺸﺒﻜﻴﺔ‬
Have you been diagnosed with any of the following bone diseases limited ‫ ﺍﻹﻧﺰﻻﻕ ﺍﻟﻐﻀﺮﻭﻓﻲ‬:‫ﻫﻞ ﺗﻢ ﺗﺸﺨﻴﺼﻚ ﺑﺄﻱ ﻣﻦ ﺃﻣﺮﺍﺽ ﺍﻟﻌﻈﺎﻡ ﺍﻟﺘﺎﻟﻴﺔ ﻓﻘﻂ‬
to:Vertebral disc prolapse (moderate or severe), Scoliosis (moderate or severe)**, or ligament
tears, osteoarthritis (moderate or severe )
* * ‫ﺗﻤﺰﻕ ﺍﻷﺭﺑﻄﺔ‬،‫ﺍﻟﺘﻬﺎﺏ ﺍﻟﻤﻔﺎﺻﻞ‬،‫ﺇﻧﺤﺮﺍﻑ ﺍﻟﻌﻤﻮﺩ ﺍﻟﻔﻘﺮﻱ‬,‫ﺍﻟﺪﻳﺴﻚ‬

Pregnant Female Only ‫ﻟﻸﻧﺜﻰ ﺍﻟﺤﺎﻣﻞ ﻓﻘﻂ‬

‫ﺣﻤﻞ ﺣﺎﻟﻲ ﺟﻨﻴﻦ ﻭﺍﺣﺪ‬
Current Single Pregnancy
* *
‫ﺣﻤﻞ ﺣﺎﻟﻲ ﻣﻊ ﻗﻴﺼﺮﻳﺔ ﺳﺎﺑﻘﺔ‬
Current Single Pregnancy with Previous CS Delivery
* *
‫ﺣﻤﻞ ﺣﺎﻟﻲ ﻣﺘﻌﺪﺩ ﺍﻷﺟﻨﺔ‬
Current Multiple Pregnancy
* *
Expected delivery date .. / .. / .... ‫ﺗﺎﺭﻳﺦ ﺍﻟﻮﻻﺩﺓ ﺍﻟﻤﺘﻮﻗﻊ‬
Employee and dependents details that need to be added ‫ﺑﻴﺎﻧﺎﺕ ﺍﻟﻤﻮﻇﻒ ﻭﺃﻓﺮﺍﺩ ﺍﻟﻌﺎﺋﻠﺔ ﺍﻟﻤﺮﺍﺩ ﺇﺿﺎﻓﺘﻬﻢ‬
In case of a yes answer above, please declare the case in the table below ‫ ﺍﻟﺮﺟﺎﺀ ﺫﻛﺮ ﺍﻟﺤﺎﻟﺔ ﻓﻲ ﺍﻟﺠﺪﻭﻝ ﺃﺩﻧﺎﻩ‬،‫ﻓﻲ ﺣﺎﻟﺔ ﺍﻹﺟﺎﺑﺔ ﺑﻨﻌﻢ ﺃﻋﻼﻩ‬
‫ﺇﺳﻢ ﻣﻘﺪﻡ ﺍﻟﺨﺪﻣﺔ‬ ‫ﺍﻟﺤﺎﻟﺔ‬ ‫ﺭﻗﻢ ﺍﻟﺠﻮﺍﻝ‬ ‫ﺍﻟﻄﻮﻝ‬ ‫ﺍﻟﻮﺯﻥ‬ ‫ﺭﻗﻢ ﺍﻟﻬﻮﻳﺔ‬ ‫ﺍﻟﻘﺮﺍﺑﺔ‬ ‫ﺍﻟﺠﻨﺲ‬ ‫ ﺃﻓﺮﺍﺩ ﺍﻟﻌﺎﺋﻠﺔ‬/ ‫ﺍﺳﻢ ﺍﻟﻤﻮﻇﻒ‬ ‫ﻡ‬
2176143259 Employee Male / ‫ ﺫﻛﺮ‬Aklas Ahmed Nooruddin 1
2
3
4
5
Undertakings : ‫ﺍﻹﻗﺮﺍﺭ ﻭﺍﻟﺘﻔﻮﻳﺾ‬
1- I hereby undertake that all the above information is correct and the acceptance of my ‫ﻭﺍﻟﻤﻌﻠﻮﻣﺎﺕ ﺍﻟﻤﺬﻛﻮﺭﺓ ﺃﻋﻼﻩ ﻛﺎﻣﻠﺔ ﻭﺻﺤﻴﺤﺔ ﻭﺑﻨﺎﺀ ﻋﻠﻴﻪ ﻓﺈﻥ ﻗﺒﻮﻝ ﺍﻟﻄﻠﺐ ﺳﻴﺘﻢ‬: ‫ ﺃﻗﺮ ﺃﻥ ﺍﻟﺒﻴﺎﻧﺎﺕ‬-1
enrollment will be on the basis of such information and that Malath Cooperative Insurance ‫ﻋﻠﻰ ﺃﺳﺎﺱ ﻫﺬﻩ ﺍﻟﺒﻴﺎﻧﺎﺕ ﻭﺃﻥ ﺷﺮﻛﺔ ﻣﻼﺫ ﻟﻠﺘﺄﻣﻴﻦ ﺍﻟﺘﻌﺎﻭﻧﻲ ﻟﻬﺎ ﺍﻟﺤﻖ ﻓﻲ ﺍﻻﺗﺼﺎﻝ ﺑﺎﻟﻤﺴﺘﺸﻔﻴﺎﺕ ﺍﻟﺘﻲ‬
Company has the right to contact the hospital(s) I deal with to collect any ‫ﺃﺗﻌﺎﻣﻞ ﻣﻌﻬﺎ ﻟﺘﺰﻭﻳﺪﻫﺎ ﺑﺄﻱ ﻣﻌﻠﻮﻣﺎﺕ ﻃﺒﻴﺔ ﻗﺪ ﺗﺤﺘﺎﺝ ﺇﻟﻴﻬﺎ ﻟﺘﻘﻴﻴﻢ ﺍﻟﻤﺨﺎﻃﺮ‬
medical information needed to assess the risk(s).

2- I agree that Malath Cooperative Insurance Company has the right to reject the ‫ ﺃﻭﺍﻓﻖ ﻋﻠﻰ ﺃﺣﻘﻴﺔ ﺷﺮﻛﺔ ﻣﻼﺫ ﻟﻠﺘﺄﻣﻴﻦ ﻓﻲ ﺭﻓﺾ ﺍﻟﻤﻄﺎﻟﺒﺔ ﺃﻭ ﺍﻟﺘﻐﻄﻴﺔ ﻛﻠﻴﺎ ﻋﻨﺪ ﻋﺪﻡ ﺍﻹﻓﺼﺎﺡ ﻋﻦ ﻭﺟﻮﺩ ﺃﻱ ﻣﻦ ﺍﻟﺤﺎﻻﺕ‬-2
coverage/claims in full in case of no declaration of any cases prior to the contractual date or ‫ﺍﻟﻤﺬﻛﻮﺭﺓ ﺃﻋﻼﻩ ﺍﻟﺘﻲ ﻧﺸﺄﺕ ﻗﺒﻞ ﺗﺎﺭﻳﺦ ﺍﻟﺘﻌﺎﻗﺪ ﺃﻭ ﻗﺒﻞ ﺗﺴﺠﻴﻞ ﺃﻭ ﺇﺿﺎﻓﺔ ﻋﻀﻮ ﺧﻼﻝ ﻓﺘﺮﺓ ﺳﺮﻳﺎﻥ ﺍﻟﻌﻘﺪ‬
before enrolling or adding a new member during the contract.

3- I hereby confirm reading and understanding all points presented in this form and I agree that ‫ ﺃﻗﺮﺑﺄﻧﻲ ﻗﺪ ﻗﺮﺃﺕ ﻭﻓﻬﻤﺖ ﺟﻤﻴﻊ ﻣﺎ ﺟﺎﺀ ﻓﻲ ﻫﺬﺍ ﺍﻟﻨﻤﻮﺫﺝ ﻛﻤﺎ ﺃﺗﻌﻬﺪ ﺑﺄﻥ ﻋﺪﻡ ﺇﺷﺎﺭﺗﻲ ﺃﻣﺎﻡ ﺃﻱ ﻣﻦ‬-3
not marking any case is understood as “Nothing requires declaration” and I sign on these ‫ﺍﻟﺤﺎﻻﺕ ﺍﻟﻤﺬﻛﻮﺭﺓ ﺃﻋﻼﻩ ﻳﻌﺘﺒﺮ ﺑﻤﺜﺎﺑﺔ ﻧﻔﻲ ﻭﺟﻮﺩ ﻣﺎﻳﺴﺘﺤﻖ ﺍﻹﻓﺼﺎﺡ ﻋﻨﻪ ﻭﻋﻠﻴﻪ ﺃﻭﻗﻊ‬
basis.
4- Failure to fill the weight and height information will result in refusal to cover
the cost of obesity surgery. ‫ ﻋﺪﻡ ﺗﻌﺒﺌﺔ ﺑﻴﺎﻧﺎﺕ ﺍﻟﻄﻮﻝ ﻭﺍﻟﻮﺯﻥ ﺳﻴﺆﺩﻱ ﺇﻟﻰ ﺭﻓﺾ ﺗﻐﻄﻴﺔ ﺗﻜﺎﻟﻴﻒ ﻋﻤﻠﻴﺔ ﺟﺮﺍﺣﺔ ﺍﻟﺴﻤﻨﺔ ﺍﻟﻤﻔﺮﻃﺔ‬-4

Entity's stamp ‫ﺧﺘﻢ ﺟﻬﺔ ﺍﻟﻌﻤﻞ‬ Insured Signature ‫ﺗﻮﻗﻴﻊ ﺍﻟﻤﻮﻇﻒ‬ Date ‫ﺍﻟﺘﺎﺭﻳﺦ‬
.. / .. / ....

New_Health_Insurance.rdf Page 29 of 39 V.20 13-DEC-2023 01:30 PM

 ‫ﻧﻤﻮﺫﺝ ﺍﻻﻓﺼﺎﺡ ﺍﻟﻄﺒﻲ ﺍﻟﻤﻮﺣﺪ‬
Unified Medical Declaration Form
Product Code: A-MLTH-2-C-08-014
Dear Insured: ‫ﻋﺰﻳﺰﻱ ﺍﻟﻤﺆﻣﻦ ﻟﻪ‬
Please Fill out the form correctly for the purpose of pricing and to ensured that you and your ‫ﻧﺄﻣﻞ ﻗﻴﺎﻣﻚ ﺑﺘﻌﺒﺌﺔ ﻫﺬﺍ ﺍﻟﻨﻤﻮﺫﺝ ﺑﺎﻟﺸﻜﻞ ﺍﻟﺼﺤﻴﺢ ﻟﻐﺮﺽ ﺍﻟﺘﺴﻌﻴﺮ ﻭﻟﻀﻤﺎﻥ ﺣﺼﻮﻟﻚ ﻭﺃﻓﺮﺍﺩ ﺃﺳﺮﺗﻚ ﻋﻠﻰ ﺧﺪﻣﺎﺕ‬
family receive health care services as required according to your unfied policy benefit ‫ﺍﻟﺮﻋﺎﻳﺔ ﺍﻟﺼﺤﻴﺔ ﺑﺎﻟﺸﻜﻞ ﺍﻟﻤﻄﻠﻮﺏ ﺣﺴﺐ ﻣﻨﺎﻓﻊ ﺍﻟﻮﺛﻴﻘﺔ ﺍﻟﻤﻮﺣﺪﺓ‬

Addition ‫ﺇﺿﺎﻓﺔ‬ New ‫ﺟﺪﻳﺪ‬ Type ‫ﻧﻮﻉ ﺍﻟﻄﻠﺐ‬

CR No 7011507360 ‫ﺍﻟﺴﺠﻞ ﺍﻟﺘﺠﺎﺭﻱ‬ Entity Name HADDAJ AL HIJAZ EST ‫ﺃﺳﻢ ﺍﻟﻤﻨﺸﺄﺓ‬
Mobile No 0551884022 ‫ﺭﻗﻢ ﺍﻟﺠﻮﺍﻝ‬ Mohammed Mohammed Abdu Qasem ‫ﺍﺳﻢ ﺍﻟﻤﻮﻇﻒ‬
ID Number 2 1 9 0 3 2 9 1 3 2 ‫ﺭﻗﻢ ﺍﻟﻬﻮﻳﺔ‬
Male / ‫ﺫﻛﺮ‬ Yemen
Gender ‫ ﺍﻟﺠﻨﺲ‬Nationality ‫ ﺍﻟﺠﻨﺴﻴﺔ‬Marital status Married R ‫ﻣﺘﺰﻭﺝ‬ Single * ‫ﺃﻋﺰﺏ‬ ‫ﺍﻟﺤﺎﻟﺔ ﺍﻻﺟﺘﻤﺎﻋﻴﺔ‬
Please declare any of the below cases by marking P under the word Yes ‫ ﻓﻲ ﺍﻟﻤﺮﺑﻊ ﺗﺤﺖ ﻛﻠﻤﺔ ﻧﻌﻢ‬P ‫ﻳﺮﺟﻰ ﺍﻹﻓﺼﺎﺡ ﻋﻦ ﻭﺟﻮﺩ ﺃﻱ ﻣﻦ ﺍﻟﺤﺎﻻﺕ ﺍﺩﻧﺎﻩ ﺑﻮﺿﻊ ﺇﺷﺎﺭﺓ‬
"Below Undeclared Medical Case May Not Be Covered" No / ‫ﻻ‬ Yes / ‫ﻧﻌـﻢ‬ "‫"ﻟﻦ ﺗﺘﻢ ﺍﻟﺘﻐﻄﻴﺔ ﺍﻟﺘﺄﻣﻴﻨﻴﺔ ﻟﻠﺤﺎﻻﺕ ﺃﺩﻧﺎﻩ ﻓﻰ ﺣﺎﻝ ﻋﺪﻡ ﺍﻹﻓﺼﺎﺡ ﻋﻨﻬﺎ‬
Any hospital admission during last 12 months. ‫ ﺷﻬﺮ‬12 ‫ﻫﻞ ﺗﻢ ﺍﻟﺘﻨﻮﻳﻢ ﺑﺎﻟﻤﺴﺘﺸﻔﻰ ﺧﻼﻝ ﺃﺧﺮ‬
"Admission: registering as an admitted patient at the hospital until the following morning "
* * " ‫ ﺗﺴﺠﻴﻞ ﺍﻟﺸﺨﺺ ﺍﻟﻤﺆﻣﻦ ﻟﻪ ﻛﻤﺮﻳﺾ ﻣﻨﻮﻡ ﻓﻲ ﺍﻟﻤﺴﺘﺸﻔﻰ ﺣﺘﻰ ﺻﺒﺎﺡ ﺍﻟﻴﻮﻡ ﺍﻟﺘﺎﻟﻲ‬: ‫" ﺍﻟﺘﻨﻮﻳﻢ‬

Have you been diagnosed with any of the following chronic disease limited ‫ﻫﻞ ﺗﻢ ﺗﺸﺨﻴﺼﻚ ﺑﺄﻯ ﻣﻦ ﺍﻷﻣﺮﺍﺽ ﺍﻟﺘﺎﻟﻴﺔ ﻓﻘﻂ‬
to:Autism, listed Benign Tumor (Breast tumors, fibroid uterus, benign prostatic hyperplasia, ‫ﺃﻭﺭﺍﻡ ﺃﻭ‬,‫ﺗﻀﺨﻢ ﺍﻟﺒﺮﻭﺳﺘﺎﺗﺎ ﺍﻟﺤﻤﻴﺪ‬,‫ ﺃﻭﺭﺍﻡ ﺍﻟﺮﺣﻢ ﺍﻟﻠﻴﻔﻰ‬, ‫ﺍﻻﻭﺭﺍﻡ ﺍﻟﺤﻤﻴﺪﺓ ﺍﻟﺘﺎﻟﻴﺔ )ﺃﻭﺭﺍﻡ ﺍﻟﺜﺪﻯ‬,‫ﺍﻷﻭﺭﺍﻡ ﺍﻟﺴﺮﻃﺎﻧﻴﺔ‬,‫ﺍﻟﺘﻮﺣﺪ‬
thyroid goiter and parathyroid glands, live tumors, colon tumors). Malignant tumors, listed ‫ﺃﻣﺮﺍﺽ ﺍﻟﻘﻠﺐ ﺍﻟﺘﺎﻟﻴﺔ)ﺃﻣﺮﺍﺽ ﺷﺮﺍﻳﻴﻦ ﻭﺻﻤﺎﻣﺎﺕ ﺗﻀﺨﻢ ﺍﻟﻐﺪﺓ ﺍﻟﺪﺭﻗﻴﺔ‬, (‫ﺃﻭﺭﺍﻡ ﺍﻟﻘﻮﻟﻮﻥ‬, ‫ﻭﺃﻭﺭﺍﻡ ﺍﻻﻟﻜﺒﺪ‬,‫ﻭ ﺍﻟﺠﺎﺭ ﺍﻟﺪﺭﻗﻴﺔ‬
Cardiac diseases coronary and valve heart diseases, heart failure, cardiac fibrillation
myocardial infraction, heart clots). Chronic Hepatitis C. Gallstones Sever Kidney failure (stage
* * ‫ﺍﻻﻟﺘﻬﺎﺏ ﺍﻟﻜﺒﺪﻯ ﺍﻟﻔﻴﺮﻭﺳﻰ ﺍﻟﻤﺰﻣﻦ‬.( ‫ﺍﻟﺮﺟﻔﺎﻥ ﺍﻟﻘﻠﺒﻰ ﻭﺟﻠﻄﺎﺕ ﺍﻟﻘﻠﺐ‬, ‫ﻓﺸﻞ ﻋﻀﻠﺔ ﺍﻟﻘﻠﺐ‬, ‫ﺣﺼﻮﺍﺕ ﺍﻟﻤﺮﺍﺭﺓ ﺍﻟﻘﻠﺐ‬, ‫ﺝ ﻭﺳﻰ‬
,‫ ﺍﻟﺘﺮﺷﻴﺢ ﺍﻟﻜﻠﻮﻯ ﺃﻗﻞ ﻣﻦ‬,‫ ﺍﻟﻔﺸﻞ ﺍﻟﻜﻠﻮﻯﺍﻟﺸﺪﻳﺪ )ﺍﻟﻤﺮﺣﻠﺔ ﺍﻟﺨﺎﻣﺴﺔ ﻣﻦ ﺍﻣﺮﺍﺽ ﺍﻟﻜﻠﻰ ﺍﻟﺘﻰ ﺗﺴﺘﺪﻋﻰ ﺍﻟﻐﺴﻴﻞ ﺍﻟﻜﻠﻮﻯ‬15
5 Requiring dialysis, clearance of less tha 15 ml/ minute*). Urinary tract ‫ﻣﺮﺽ‬, ‫ﺩﻗﻴﻘﺔ(ﺣﺼﻮﺍﺕ ﺍﻟﻤﺴﺎﻟﻚ ﺍﻟﺒﻮﻟﻴﺔﺃﻣﺮﺍﺽ ﺍﻟﻤﻨﺎﻋﺔ ﺍﻟﺘﺎﻟﻴﺔ )ﺍﻟﺬﺋﺒﺔ ﺍﻟﺤﻤﺮﺍﺀﻭﺍﻟﺘﻬﺎﺏ ﺍﻟﻤﻔﺎﺻﻞ ﺍﻟﺮﻭﻣﺎﺗﻴﺰﻣﻴﺔﻭ ﺍﻟﺼﺪﻓﻴﺔ‬/‫ﻣﻞ‬
stones, hernias. Autoimmune disease (lupus, rheumatoid arthritis, psoriasis, Crohn's disease, ‫ﺍﻟﺘﻬﺎﺏ ﺍﻟﻘﻮﻟﻮﻥ ﺍﻟﺘﻘﺮﺣﻰ‬, ‫ﻛﺮﻭﻧﺰ‬,
ulcerative colitis,multiple sclerosis, celiac disease) ‫ﺣﺴﺎﺳﻴﺔ ﺍﻟﻘﻤﺢ‬, ‫ﺍﻟﺘﺼﻠﺐ ﺍﻟﻠﻮﻳﺤﻰ‬

Have you been diagnosed with any of the following congenital disorder or
hereditary diseases limited to: Cerebral palsy, Sickle cell disorder, Thalassemia, ‫ﻫﻞ ﺗﻢ ﺗﺸﺨﻴﺼﻚ ﺑﺄﻱ ﻣﻦ ﺍﻷﻣﺮﺍﺽ ﺍﻟﻮﺭﺍﺛﻴﺔ ﺃﻭ ﺍﻟﺘﺸﻮﻫﺎﺕ ﺍﻟﺨﻠﻘﻴﺔ ﺍﻟﺘﺎﻟﻴﺔ ﻓﻘﻂ‬
hemophilia, metabolic diseases, Hydrocephalus, spinal muscle atrophy, genital ‫ ﺿﻤﻮﺭ‬،‫ ﺃﺳﺘﺴﻘﺎﺀ ﺍﻟﺮﺃﺱ‬،‫ ﺃﻣﺮﺍﺽ ﺍﻟﺘﻤﺜﻴﻞ ﺍﻟﻐﺬﺍﺋﻲ‬،‫ ﺍﻟﻬﻴﻤﻮﻓﻴﻠﻴﺎ‬،‫ ﺍﻟﺘﻼﺳﻴﻤﻴﺎ‬،‫ﺍﺿﻄﺮﺍﺏ ﺍﻟﺨﻼﻳﺎ ﺍﻟﻤﻨﺠﻠﻴﺔ‬, ‫ﺍﻟﺸﻠﻞ ﺍﻟﺪﻣﺎﻏﻰ‬
malformations, chromosomal abnormalities. Gaucher's disease, G6PD Deficiency, cystic
fibrosis, hemochromatosis, Wilson disease. Polycystic Kidney Disease.
* * ‫ ﻣﺮﺽ ﺍﻟﺘﻜﺴﺮﺍﻟﻔﻮﻟﻰ‬،‫ ﻣﺮﺽ ﻏﻮﺷﺮ‬،‫ ﺃﻣﺮﺍﺽ ﺍﻟﻜﺮﻭﻣﻮﺳﻮﻣﺎﺕ‬،‫ ﺗﺸﻮﻫﺎﺕ ﺍﻷﻋﻀﺎﺀ ﺍﻟﺘﻨﺎﺳﻠﻴﺔ‬،‫ﺍﻟﻌﻀﻼﺕ ﺍﻟﺸﻮﻛﻲ‬
‫ﺗﻜﻴﺲ‬,‫ﻣﺮﺽ ﻭﻳﻠﺴﻮﻥ‬, (‫ ﻣﺮﺽ ﺗﻜﺪﺱ ﺍﻟﺤﺪﻳﺪ )ﻫﻴﻤﻮﻛﺮﻭﻣﺎﺗﻮﺳﻴﺲ‬،‫( ﺍﻟﺘﻠﻴﻒ ﺍﻟﻜﻴﺴﻲ ﻟﻠﺮﺋﺔ‬G6PD)
‫ﺍﻟﻜﻠﻴﺘﻴﻦ ﺍﻟﺨﻠﻔﻰ ﺍﻟﻮﺭﺍﺋﻰ‬

Have you been diagnosed with any of following eye diseases limited to: ،‫ ﻣﻴﺎﺓ ﺯﺭﻗﺎﺀ‬،‫ ﻣﻴﺎﺓ ﺑﻴﻀﺎﺀ‬:‫ﻫﻞ ﺗﻢ ﺗﺸﺨﻴﺼﻚ ﺑﺄﻱ ﻣﻦ ﺃﻣﺮﺍﺽ ﺍﻟﻌﻴﻦ ﺍﻟﺘﺎﻟﻴﺔ ﻓﻘﻂ‬
Cataract, Glaucoma, Retinal diseases. * * ‫ﺃﻣﺮﺍﺽ ﺍﻟﺸﺒﻜﻴﺔ‬
Have you been diagnosed with any of the following bone diseases limited ‫ ﺍﻹﻧﺰﻻﻕ ﺍﻟﻐﻀﺮﻭﻓﻲ‬:‫ﻫﻞ ﺗﻢ ﺗﺸﺨﻴﺼﻚ ﺑﺄﻱ ﻣﻦ ﺃﻣﺮﺍﺽ ﺍﻟﻌﻈﺎﻡ ﺍﻟﺘﺎﻟﻴﺔ ﻓﻘﻂ‬
to:Vertebral disc prolapse (moderate or severe), Scoliosis (moderate or severe)**, or ligament
tears, osteoarthritis (moderate or severe )
* * ‫ﺗﻤﺰﻕ ﺍﻷﺭﺑﻄﺔ‬،‫ﺍﻟﺘﻬﺎﺏ ﺍﻟﻤﻔﺎﺻﻞ‬،‫ﺇﻧﺤﺮﺍﻑ ﺍﻟﻌﻤﻮﺩ ﺍﻟﻔﻘﺮﻱ‬,‫ﺍﻟﺪﻳﺴﻚ‬

Pregnant Female Only ‫ﻟﻸﻧﺜﻰ ﺍﻟﺤﺎﻣﻞ ﻓﻘﻂ‬

‫ﺣﻤﻞ ﺣﺎﻟﻲ ﺟﻨﻴﻦ ﻭﺍﺣﺪ‬
Current Single Pregnancy
* *
‫ﺣﻤﻞ ﺣﺎﻟﻲ ﻣﻊ ﻗﻴﺼﺮﻳﺔ ﺳﺎﺑﻘﺔ‬
Current Single Pregnancy with Previous CS Delivery
* *
‫ﺣﻤﻞ ﺣﺎﻟﻲ ﻣﺘﻌﺪﺩ ﺍﻷﺟﻨﺔ‬
Current Multiple Pregnancy
* *
Expected delivery date .. / .. / .... ‫ﺗﺎﺭﻳﺦ ﺍﻟﻮﻻﺩﺓ ﺍﻟﻤﺘﻮﻗﻊ‬
Employee and dependents details that need to be added ‫ﺑﻴﺎﻧﺎﺕ ﺍﻟﻤﻮﻇﻒ ﻭﺃﻓﺮﺍﺩ ﺍﻟﻌﺎﺋﻠﺔ ﺍﻟﻤﺮﺍﺩ ﺇﺿﺎﻓﺘﻬﻢ‬
In case of a yes answer above, please declare the case in the table below ‫ ﺍﻟﺮﺟﺎﺀ ﺫﻛﺮ ﺍﻟﺤﺎﻟﺔ ﻓﻲ ﺍﻟﺠﺪﻭﻝ ﺃﺩﻧﺎﻩ‬،‫ﻓﻲ ﺣﺎﻟﺔ ﺍﻹﺟﺎﺑﺔ ﺑﻨﻌﻢ ﺃﻋﻼﻩ‬
‫ﺇﺳﻢ ﻣﻘﺪﻡ ﺍﻟﺨﺪﻣﺔ‬ ‫ﺍﻟﺤﺎﻟﺔ‬ ‫ﺭﻗﻢ ﺍﻟﺠﻮﺍﻝ‬ ‫ﺍﻟﻄﻮﻝ‬ ‫ﺍﻟﻮﺯﻥ‬ ‫ﺭﻗﻢ ﺍﻟﻬﻮﻳﺔ‬ ‫ﺍﻟﻘﺮﺍﺑﺔ‬ ‫ﺍﻟﺠﻨﺲ‬ ‫ ﺃﻓﺮﺍﺩ ﺍﻟﻌﺎﺋﻠﺔ‬/ ‫ﺍﺳﻢ ﺍﻟﻤﻮﻇﻒ‬ ‫ﻡ‬
2190329132 Employee Male / ‫ ﺫﻛﺮ‬Mohammed Mohammed Abdu 1
2
3
4
5
Undertakings : ‫ﺍﻹﻗﺮﺍﺭ ﻭﺍﻟﺘﻔﻮﻳﺾ‬
1- I hereby undertake that all the above information is correct and the acceptance of my ‫ﻭﺍﻟﻤﻌﻠﻮﻣﺎﺕ ﺍﻟﻤﺬﻛﻮﺭﺓ ﺃﻋﻼﻩ ﻛﺎﻣﻠﺔ ﻭﺻﺤﻴﺤﺔ ﻭﺑﻨﺎﺀ ﻋﻠﻴﻪ ﻓﺈﻥ ﻗﺒﻮﻝ ﺍﻟﻄﻠﺐ ﺳﻴﺘﻢ‬: ‫ ﺃﻗﺮ ﺃﻥ ﺍﻟﺒﻴﺎﻧﺎﺕ‬-1
enrollment will be on the basis of such information and that Malath Cooperative Insurance ‫ﻋﻠﻰ ﺃﺳﺎﺱ ﻫﺬﻩ ﺍﻟﺒﻴﺎﻧﺎﺕ ﻭﺃﻥ ﺷﺮﻛﺔ ﻣﻼﺫ ﻟﻠﺘﺄﻣﻴﻦ ﺍﻟﺘﻌﺎﻭﻧﻲ ﻟﻬﺎ ﺍﻟﺤﻖ ﻓﻲ ﺍﻻﺗﺼﺎﻝ ﺑﺎﻟﻤﺴﺘﺸﻔﻴﺎﺕ ﺍﻟﺘﻲ‬
Company has the right to contact the hospital(s) I deal with to collect any ‫ﺃﺗﻌﺎﻣﻞ ﻣﻌﻬﺎ ﻟﺘﺰﻭﻳﺪﻫﺎ ﺑﺄﻱ ﻣﻌﻠﻮﻣﺎﺕ ﻃﺒﻴﺔ ﻗﺪ ﺗﺤﺘﺎﺝ ﺇﻟﻴﻬﺎ ﻟﺘﻘﻴﻴﻢ ﺍﻟﻤﺨﺎﻃﺮ‬
medical information needed to assess the risk(s).

2- I agree that Malath Cooperative Insurance Company has the right to reject the ‫ ﺃﻭﺍﻓﻖ ﻋﻠﻰ ﺃﺣﻘﻴﺔ ﺷﺮﻛﺔ ﻣﻼﺫ ﻟﻠﺘﺄﻣﻴﻦ ﻓﻲ ﺭﻓﺾ ﺍﻟﻤﻄﺎﻟﺒﺔ ﺃﻭ ﺍﻟﺘﻐﻄﻴﺔ ﻛﻠﻴﺎ ﻋﻨﺪ ﻋﺪﻡ ﺍﻹﻓﺼﺎﺡ ﻋﻦ ﻭﺟﻮﺩ ﺃﻱ ﻣﻦ ﺍﻟﺤﺎﻻﺕ‬-2
coverage/claims in full in case of no declaration of any cases prior to the contractual date or ‫ﺍﻟﻤﺬﻛﻮﺭﺓ ﺃﻋﻼﻩ ﺍﻟﺘﻲ ﻧﺸﺄﺕ ﻗﺒﻞ ﺗﺎﺭﻳﺦ ﺍﻟﺘﻌﺎﻗﺪ ﺃﻭ ﻗﺒﻞ ﺗﺴﺠﻴﻞ ﺃﻭ ﺇﺿﺎﻓﺔ ﻋﻀﻮ ﺧﻼﻝ ﻓﺘﺮﺓ ﺳﺮﻳﺎﻥ ﺍﻟﻌﻘﺪ‬
before enrolling or adding a new member during the contract.

3- I hereby confirm reading and understanding all points presented in this form and I agree that ‫ ﺃﻗﺮﺑﺄﻧﻲ ﻗﺪ ﻗﺮﺃﺕ ﻭﻓﻬﻤﺖ ﺟﻤﻴﻊ ﻣﺎ ﺟﺎﺀ ﻓﻲ ﻫﺬﺍ ﺍﻟﻨﻤﻮﺫﺝ ﻛﻤﺎ ﺃﺗﻌﻬﺪ ﺑﺄﻥ ﻋﺪﻡ ﺇﺷﺎﺭﺗﻲ ﺃﻣﺎﻡ ﺃﻱ ﻣﻦ‬-3
not marking any case is understood as “Nothing requires declaration” and I sign on these ‫ﺍﻟﺤﺎﻻﺕ ﺍﻟﻤﺬﻛﻮﺭﺓ ﺃﻋﻼﻩ ﻳﻌﺘﺒﺮ ﺑﻤﺜﺎﺑﺔ ﻧﻔﻲ ﻭﺟﻮﺩ ﻣﺎﻳﺴﺘﺤﻖ ﺍﻹﻓﺼﺎﺡ ﻋﻨﻪ ﻭﻋﻠﻴﻪ ﺃﻭﻗﻊ‬
basis.
4- Failure to fill the weight and height information will result in refusal to cover
the cost of obesity surgery. ‫ ﻋﺪﻡ ﺗﻌﺒﺌﺔ ﺑﻴﺎﻧﺎﺕ ﺍﻟﻄﻮﻝ ﻭﺍﻟﻮﺯﻥ ﺳﻴﺆﺩﻱ ﺇﻟﻰ ﺭﻓﺾ ﺗﻐﻄﻴﺔ ﺗﻜﺎﻟﻴﻒ ﻋﻤﻠﻴﺔ ﺟﺮﺍﺣﺔ ﺍﻟﺴﻤﻨﺔ ﺍﻟﻤﻔﺮﻃﺔ‬-4

Entity's stamp ‫ﺧﺘﻢ ﺟﻬﺔ ﺍﻟﻌﻤﻞ‬ Insured Signature ‫ﺗﻮﻗﻴﻊ ﺍﻟﻤﻮﻇﻒ‬ Date ‫ﺍﻟﺘﺎﺭﻳﺦ‬
.. / .. / ....

New_Health_Insurance.rdf Page 30 of 39 V.20 13-DEC-2023 01:30 PM

 ‫ﻧﻤﻮﺫﺝ ﺍﻻﻓﺼﺎﺡ ﺍﻟﻄﺒﻲ ﺍﻟﻤﻮﺣﺪ‬
Unified Medical Declaration Form
Product Code: A-MLTH-2-C-08-014
Dear Insured: ‫ﻋﺰﻳﺰﻱ ﺍﻟﻤﺆﻣﻦ ﻟﻪ‬
Please Fill out the form correctly for the purpose of pricing and to ensured that you and your ‫ﻧﺄﻣﻞ ﻗﻴﺎﻣﻚ ﺑﺘﻌﺒﺌﺔ ﻫﺬﺍ ﺍﻟﻨﻤﻮﺫﺝ ﺑﺎﻟﺸﻜﻞ ﺍﻟﺼﺤﻴﺢ ﻟﻐﺮﺽ ﺍﻟﺘﺴﻌﻴﺮ ﻭﻟﻀﻤﺎﻥ ﺣﺼﻮﻟﻚ ﻭﺃﻓﺮﺍﺩ ﺃﺳﺮﺗﻚ ﻋﻠﻰ ﺧﺪﻣﺎﺕ‬
family receive health care services as required according to your unfied policy benefit ‫ﺍﻟﺮﻋﺎﻳﺔ ﺍﻟﺼﺤﻴﺔ ﺑﺎﻟﺸﻜﻞ ﺍﻟﻤﻄﻠﻮﺏ ﺣﺴﺐ ﻣﻨﺎﻓﻊ ﺍﻟﻮﺛﻴﻘﺔ ﺍﻟﻤﻮﺣﺪﺓ‬

Addition ‫ﺇﺿﺎﻓﺔ‬ New ‫ﺟﺪﻳﺪ‬ Type ‫ﻧﻮﻉ ﺍﻟﻄﻠﺐ‬

CR No 7011507360 ‫ﺍﻟﺴﺠﻞ ﺍﻟﺘﺠﺎﺭﻱ‬ Entity Name HADDAJ AL HIJAZ EST ‫ﺃﺳﻢ ﺍﻟﻤﻨﺸﺄﺓ‬
Mobile No 0537519174 ‫ﺭﻗﻢ ﺍﻟﺠﻮﺍﻝ‬ Sahed Mhmed - - Shhamsuddain ‫ﺍﺳﻢ ﺍﻟﻤﻮﻇﻒ‬
ID Number 2 1 9 0 4 3 6 6 1 4 ‫ﺭﻗﻢ ﺍﻟﻬﻮﻳﺔ‬
Male / ‫ﺫﻛﺮ‬ Bangladesh
Gender ‫ ﺍﻟﺠﻨﺲ‬Nationality ‫ ﺍﻟﺠﻨﺴﻴﺔ‬Marital status Married R ‫ﻣﺘﺰﻭﺝ‬ Single * ‫ﺃﻋﺰﺏ‬ ‫ﺍﻟﺤﺎﻟﺔ ﺍﻻﺟﺘﻤﺎﻋﻴﺔ‬
Please declare any of the below cases by marking P under the word Yes ‫ ﻓﻲ ﺍﻟﻤﺮﺑﻊ ﺗﺤﺖ ﻛﻠﻤﺔ ﻧﻌﻢ‬P ‫ﻳﺮﺟﻰ ﺍﻹﻓﺼﺎﺡ ﻋﻦ ﻭﺟﻮﺩ ﺃﻱ ﻣﻦ ﺍﻟﺤﺎﻻﺕ ﺍﺩﻧﺎﻩ ﺑﻮﺿﻊ ﺇﺷﺎﺭﺓ‬
"Below Undeclared Medical Case May Not Be Covered" No / ‫ﻻ‬ Yes / ‫ﻧﻌـﻢ‬ "‫"ﻟﻦ ﺗﺘﻢ ﺍﻟﺘﻐﻄﻴﺔ ﺍﻟﺘﺄﻣﻴﻨﻴﺔ ﻟﻠﺤﺎﻻﺕ ﺃﺩﻧﺎﻩ ﻓﻰ ﺣﺎﻝ ﻋﺪﻡ ﺍﻹﻓﺼﺎﺡ ﻋﻨﻬﺎ‬
Any hospital admission during last 12 months. ‫ ﺷﻬﺮ‬12 ‫ﻫﻞ ﺗﻢ ﺍﻟﺘﻨﻮﻳﻢ ﺑﺎﻟﻤﺴﺘﺸﻔﻰ ﺧﻼﻝ ﺃﺧﺮ‬
"Admission: registering as an admitted patient at the hospital until the following morning "
* * " ‫ ﺗﺴﺠﻴﻞ ﺍﻟﺸﺨﺺ ﺍﻟﻤﺆﻣﻦ ﻟﻪ ﻛﻤﺮﻳﺾ ﻣﻨﻮﻡ ﻓﻲ ﺍﻟﻤﺴﺘﺸﻔﻰ ﺣﺘﻰ ﺻﺒﺎﺡ ﺍﻟﻴﻮﻡ ﺍﻟﺘﺎﻟﻲ‬: ‫" ﺍﻟﺘﻨﻮﻳﻢ‬

Have you been diagnosed with any of the following chronic disease limited ‫ﻫﻞ ﺗﻢ ﺗﺸﺨﻴﺼﻚ ﺑﺄﻯ ﻣﻦ ﺍﻷﻣﺮﺍﺽ ﺍﻟﺘﺎﻟﻴﺔ ﻓﻘﻂ‬
to:Autism, listed Benign Tumor (Breast tumors, fibroid uterus, benign prostatic hyperplasia, ‫ﺃﻭﺭﺍﻡ ﺃﻭ‬,‫ﺗﻀﺨﻢ ﺍﻟﺒﺮﻭﺳﺘﺎﺗﺎ ﺍﻟﺤﻤﻴﺪ‬,‫ ﺃﻭﺭﺍﻡ ﺍﻟﺮﺣﻢ ﺍﻟﻠﻴﻔﻰ‬, ‫ﺍﻻﻭﺭﺍﻡ ﺍﻟﺤﻤﻴﺪﺓ ﺍﻟﺘﺎﻟﻴﺔ )ﺃﻭﺭﺍﻡ ﺍﻟﺜﺪﻯ‬,‫ﺍﻷﻭﺭﺍﻡ ﺍﻟﺴﺮﻃﺎﻧﻴﺔ‬,‫ﺍﻟﺘﻮﺣﺪ‬
thyroid goiter and parathyroid glands, live tumors, colon tumors). Malignant tumors, listed ‫ﺃﻣﺮﺍﺽ ﺍﻟﻘﻠﺐ ﺍﻟﺘﺎﻟﻴﺔ)ﺃﻣﺮﺍﺽ ﺷﺮﺍﻳﻴﻦ ﻭﺻﻤﺎﻣﺎﺕ ﺗﻀﺨﻢ ﺍﻟﻐﺪﺓ ﺍﻟﺪﺭﻗﻴﺔ‬, (‫ﺃﻭﺭﺍﻡ ﺍﻟﻘﻮﻟﻮﻥ‬, ‫ﻭﺃﻭﺭﺍﻡ ﺍﻻﻟﻜﺒﺪ‬,‫ﻭ ﺍﻟﺠﺎﺭ ﺍﻟﺪﺭﻗﻴﺔ‬
Cardiac diseases coronary and valve heart diseases, heart failure, cardiac fibrillation
myocardial infraction, heart clots). Chronic Hepatitis C. Gallstones Sever Kidney failure (stage
* * ‫ﺍﻻﻟﺘﻬﺎﺏ ﺍﻟﻜﺒﺪﻯ ﺍﻟﻔﻴﺮﻭﺳﻰ ﺍﻟﻤﺰﻣﻦ‬.( ‫ﺍﻟﺮﺟﻔﺎﻥ ﺍﻟﻘﻠﺒﻰ ﻭﺟﻠﻄﺎﺕ ﺍﻟﻘﻠﺐ‬, ‫ﻓﺸﻞ ﻋﻀﻠﺔ ﺍﻟﻘﻠﺐ‬, ‫ﺣﺼﻮﺍﺕ ﺍﻟﻤﺮﺍﺭﺓ ﺍﻟﻘﻠﺐ‬, ‫ﺝ ﻭﺳﻰ‬
,‫ ﺍﻟﺘﺮﺷﻴﺢ ﺍﻟﻜﻠﻮﻯ ﺃﻗﻞ ﻣﻦ‬,‫ ﺍﻟﻔﺸﻞ ﺍﻟﻜﻠﻮﻯﺍﻟﺸﺪﻳﺪ )ﺍﻟﻤﺮﺣﻠﺔ ﺍﻟﺨﺎﻣﺴﺔ ﻣﻦ ﺍﻣﺮﺍﺽ ﺍﻟﻜﻠﻰ ﺍﻟﺘﻰ ﺗﺴﺘﺪﻋﻰ ﺍﻟﻐﺴﻴﻞ ﺍﻟﻜﻠﻮﻯ‬15
5 Requiring dialysis, clearance of less tha 15 ml/ minute*). Urinary tract ‫ﻣﺮﺽ‬, ‫ﺩﻗﻴﻘﺔ(ﺣﺼﻮﺍﺕ ﺍﻟﻤﺴﺎﻟﻚ ﺍﻟﺒﻮﻟﻴﺔﺃﻣﺮﺍﺽ ﺍﻟﻤﻨﺎﻋﺔ ﺍﻟﺘﺎﻟﻴﺔ )ﺍﻟﺬﺋﺒﺔ ﺍﻟﺤﻤﺮﺍﺀﻭﺍﻟﺘﻬﺎﺏ ﺍﻟﻤﻔﺎﺻﻞ ﺍﻟﺮﻭﻣﺎﺗﻴﺰﻣﻴﺔﻭ ﺍﻟﺼﺪﻓﻴﺔ‬/‫ﻣﻞ‬
stones, hernias. Autoimmune disease (lupus, rheumatoid arthritis, psoriasis, Crohn's disease, ‫ﺍﻟﺘﻬﺎﺏ ﺍﻟﻘﻮﻟﻮﻥ ﺍﻟﺘﻘﺮﺣﻰ‬, ‫ﻛﺮﻭﻧﺰ‬,
ulcerative colitis,multiple sclerosis, celiac disease) ‫ﺣﺴﺎﺳﻴﺔ ﺍﻟﻘﻤﺢ‬, ‫ﺍﻟﺘﺼﻠﺐ ﺍﻟﻠﻮﻳﺤﻰ‬

Have you been diagnosed with any of the following congenital disorder or
hereditary diseases limited to: Cerebral palsy, Sickle cell disorder, Thalassemia, ‫ﻫﻞ ﺗﻢ ﺗﺸﺨﻴﺼﻚ ﺑﺄﻱ ﻣﻦ ﺍﻷﻣﺮﺍﺽ ﺍﻟﻮﺭﺍﺛﻴﺔ ﺃﻭ ﺍﻟﺘﺸﻮﻫﺎﺕ ﺍﻟﺨﻠﻘﻴﺔ ﺍﻟﺘﺎﻟﻴﺔ ﻓﻘﻂ‬
hemophilia, metabolic diseases, Hydrocephalus, spinal muscle atrophy, genital ‫ ﺿﻤﻮﺭ‬،‫ ﺃﺳﺘﺴﻘﺎﺀ ﺍﻟﺮﺃﺱ‬،‫ ﺃﻣﺮﺍﺽ ﺍﻟﺘﻤﺜﻴﻞ ﺍﻟﻐﺬﺍﺋﻲ‬،‫ ﺍﻟﻬﻴﻤﻮﻓﻴﻠﻴﺎ‬،‫ ﺍﻟﺘﻼﺳﻴﻤﻴﺎ‬،‫ﺍﺿﻄﺮﺍﺏ ﺍﻟﺨﻼﻳﺎ ﺍﻟﻤﻨﺠﻠﻴﺔ‬, ‫ﺍﻟﺸﻠﻞ ﺍﻟﺪﻣﺎﻏﻰ‬
malformations, chromosomal abnormalities. Gaucher's disease, G6PD Deficiency, cystic
fibrosis, hemochromatosis, Wilson disease. Polycystic Kidney Disease.
* * ‫ ﻣﺮﺽ ﺍﻟﺘﻜﺴﺮﺍﻟﻔﻮﻟﻰ‬،‫ ﻣﺮﺽ ﻏﻮﺷﺮ‬،‫ ﺃﻣﺮﺍﺽ ﺍﻟﻜﺮﻭﻣﻮﺳﻮﻣﺎﺕ‬،‫ ﺗﺸﻮﻫﺎﺕ ﺍﻷﻋﻀﺎﺀ ﺍﻟﺘﻨﺎﺳﻠﻴﺔ‬،‫ﺍﻟﻌﻀﻼﺕ ﺍﻟﺸﻮﻛﻲ‬
‫ﺗﻜﻴﺲ‬,‫ﻣﺮﺽ ﻭﻳﻠﺴﻮﻥ‬, (‫ ﻣﺮﺽ ﺗﻜﺪﺱ ﺍﻟﺤﺪﻳﺪ )ﻫﻴﻤﻮﻛﺮﻭﻣﺎﺗﻮﺳﻴﺲ‬،‫( ﺍﻟﺘﻠﻴﻒ ﺍﻟﻜﻴﺴﻲ ﻟﻠﺮﺋﺔ‬G6PD)
‫ﺍﻟﻜﻠﻴﺘﻴﻦ ﺍﻟﺨﻠﻔﻰ ﺍﻟﻮﺭﺍﺋﻰ‬

Have you been diagnosed with any of following eye diseases limited to: ،‫ ﻣﻴﺎﺓ ﺯﺭﻗﺎﺀ‬،‫ ﻣﻴﺎﺓ ﺑﻴﻀﺎﺀ‬:‫ﻫﻞ ﺗﻢ ﺗﺸﺨﻴﺼﻚ ﺑﺄﻱ ﻣﻦ ﺃﻣﺮﺍﺽ ﺍﻟﻌﻴﻦ ﺍﻟﺘﺎﻟﻴﺔ ﻓﻘﻂ‬
Cataract, Glaucoma, Retinal diseases. * * ‫ﺃﻣﺮﺍﺽ ﺍﻟﺸﺒﻜﻴﺔ‬
Have you been diagnosed with any of the following bone diseases limited ‫ ﺍﻹﻧﺰﻻﻕ ﺍﻟﻐﻀﺮﻭﻓﻲ‬:‫ﻫﻞ ﺗﻢ ﺗﺸﺨﻴﺼﻚ ﺑﺄﻱ ﻣﻦ ﺃﻣﺮﺍﺽ ﺍﻟﻌﻈﺎﻡ ﺍﻟﺘﺎﻟﻴﺔ ﻓﻘﻂ‬
to:Vertebral disc prolapse (moderate or severe), Scoliosis (moderate or severe)**, or ligament
tears, osteoarthritis (moderate or severe )
* * ‫ﺗﻤﺰﻕ ﺍﻷﺭﺑﻄﺔ‬،‫ﺍﻟﺘﻬﺎﺏ ﺍﻟﻤﻔﺎﺻﻞ‬،‫ﺇﻧﺤﺮﺍﻑ ﺍﻟﻌﻤﻮﺩ ﺍﻟﻔﻘﺮﻱ‬,‫ﺍﻟﺪﻳﺴﻚ‬

Pregnant Female Only ‫ﻟﻸﻧﺜﻰ ﺍﻟﺤﺎﻣﻞ ﻓﻘﻂ‬

‫ﺣﻤﻞ ﺣﺎﻟﻲ ﺟﻨﻴﻦ ﻭﺍﺣﺪ‬
Current Single Pregnancy
* *
‫ﺣﻤﻞ ﺣﺎﻟﻲ ﻣﻊ ﻗﻴﺼﺮﻳﺔ ﺳﺎﺑﻘﺔ‬
Current Single Pregnancy with Previous CS Delivery
* *
‫ﺣﻤﻞ ﺣﺎﻟﻲ ﻣﺘﻌﺪﺩ ﺍﻷﺟﻨﺔ‬
Current Multiple Pregnancy
* *
Expected delivery date .. / .. / .... ‫ﺗﺎﺭﻳﺦ ﺍﻟﻮﻻﺩﺓ ﺍﻟﻤﺘﻮﻗﻊ‬
Employee and dependents details that need to be added ‫ﺑﻴﺎﻧﺎﺕ ﺍﻟﻤﻮﻇﻒ ﻭﺃﻓﺮﺍﺩ ﺍﻟﻌﺎﺋﻠﺔ ﺍﻟﻤﺮﺍﺩ ﺇﺿﺎﻓﺘﻬﻢ‬
In case of a yes answer above, please declare the case in the table below ‫ ﺍﻟﺮﺟﺎﺀ ﺫﻛﺮ ﺍﻟﺤﺎﻟﺔ ﻓﻲ ﺍﻟﺠﺪﻭﻝ ﺃﺩﻧﺎﻩ‬،‫ﻓﻲ ﺣﺎﻟﺔ ﺍﻹﺟﺎﺑﺔ ﺑﻨﻌﻢ ﺃﻋﻼﻩ‬
‫ﺇﺳﻢ ﻣﻘﺪﻡ ﺍﻟﺨﺪﻣﺔ‬ ‫ﺍﻟﺤﺎﻟﺔ‬ ‫ﺭﻗﻢ ﺍﻟﺠﻮﺍﻝ‬ ‫ﺍﻟﻄﻮﻝ‬ ‫ﺍﻟﻮﺯﻥ‬ ‫ﺭﻗﻢ ﺍﻟﻬﻮﻳﺔ‬ ‫ﺍﻟﻘﺮﺍﺑﺔ‬ ‫ﺍﻟﺠﻨﺲ‬ ‫ ﺃﻓﺮﺍﺩ ﺍﻟﻌﺎﺋﻠﺔ‬/ ‫ﺍﺳﻢ ﺍﻟﻤﻮﻇﻒ‬ ‫ﻡ‬
2190436614 Employee Male / ‫ ﺫﻛﺮ‬Sahed Mhmed - - Shhamsudda 1
2
3
4
5
Undertakings : ‫ﺍﻹﻗﺮﺍﺭ ﻭﺍﻟﺘﻔﻮﻳﺾ‬
1- I hereby undertake that all the above information is correct and the acceptance of my ‫ﻭﺍﻟﻤﻌﻠﻮﻣﺎﺕ ﺍﻟﻤﺬﻛﻮﺭﺓ ﺃﻋﻼﻩ ﻛﺎﻣﻠﺔ ﻭﺻﺤﻴﺤﺔ ﻭﺑﻨﺎﺀ ﻋﻠﻴﻪ ﻓﺈﻥ ﻗﺒﻮﻝ ﺍﻟﻄﻠﺐ ﺳﻴﺘﻢ‬: ‫ ﺃﻗﺮ ﺃﻥ ﺍﻟﺒﻴﺎﻧﺎﺕ‬-1
enrollment will be on the basis of such information and that Malath Cooperative Insurance ‫ﻋﻠﻰ ﺃﺳﺎﺱ ﻫﺬﻩ ﺍﻟﺒﻴﺎﻧﺎﺕ ﻭﺃﻥ ﺷﺮﻛﺔ ﻣﻼﺫ ﻟﻠﺘﺄﻣﻴﻦ ﺍﻟﺘﻌﺎﻭﻧﻲ ﻟﻬﺎ ﺍﻟﺤﻖ ﻓﻲ ﺍﻻﺗﺼﺎﻝ ﺑﺎﻟﻤﺴﺘﺸﻔﻴﺎﺕ ﺍﻟﺘﻲ‬
Company has the right to contact the hospital(s) I deal with to collect any ‫ﺃﺗﻌﺎﻣﻞ ﻣﻌﻬﺎ ﻟﺘﺰﻭﻳﺪﻫﺎ ﺑﺄﻱ ﻣﻌﻠﻮﻣﺎﺕ ﻃﺒﻴﺔ ﻗﺪ ﺗﺤﺘﺎﺝ ﺇﻟﻴﻬﺎ ﻟﺘﻘﻴﻴﻢ ﺍﻟﻤﺨﺎﻃﺮ‬
medical information needed to assess the risk(s).

2- I agree that Malath Cooperative Insurance Company has the right to reject the ‫ ﺃﻭﺍﻓﻖ ﻋﻠﻰ ﺃﺣﻘﻴﺔ ﺷﺮﻛﺔ ﻣﻼﺫ ﻟﻠﺘﺄﻣﻴﻦ ﻓﻲ ﺭﻓﺾ ﺍﻟﻤﻄﺎﻟﺒﺔ ﺃﻭ ﺍﻟﺘﻐﻄﻴﺔ ﻛﻠﻴﺎ ﻋﻨﺪ ﻋﺪﻡ ﺍﻹﻓﺼﺎﺡ ﻋﻦ ﻭﺟﻮﺩ ﺃﻱ ﻣﻦ ﺍﻟﺤﺎﻻﺕ‬-2
coverage/claims in full in case of no declaration of any cases prior to the contractual date or ‫ﺍﻟﻤﺬﻛﻮﺭﺓ ﺃﻋﻼﻩ ﺍﻟﺘﻲ ﻧﺸﺄﺕ ﻗﺒﻞ ﺗﺎﺭﻳﺦ ﺍﻟﺘﻌﺎﻗﺪ ﺃﻭ ﻗﺒﻞ ﺗﺴﺠﻴﻞ ﺃﻭ ﺇﺿﺎﻓﺔ ﻋﻀﻮ ﺧﻼﻝ ﻓﺘﺮﺓ ﺳﺮﻳﺎﻥ ﺍﻟﻌﻘﺪ‬
before enrolling or adding a new member during the contract.

3- I hereby confirm reading and understanding all points presented in this form and I agree that ‫ ﺃﻗﺮﺑﺄﻧﻲ ﻗﺪ ﻗﺮﺃﺕ ﻭﻓﻬﻤﺖ ﺟﻤﻴﻊ ﻣﺎ ﺟﺎﺀ ﻓﻲ ﻫﺬﺍ ﺍﻟﻨﻤﻮﺫﺝ ﻛﻤﺎ ﺃﺗﻌﻬﺪ ﺑﺄﻥ ﻋﺪﻡ ﺇﺷﺎﺭﺗﻲ ﺃﻣﺎﻡ ﺃﻱ ﻣﻦ‬-3
not marking any case is understood as “Nothing requires declaration” and I sign on these ‫ﺍﻟﺤﺎﻻﺕ ﺍﻟﻤﺬﻛﻮﺭﺓ ﺃﻋﻼﻩ ﻳﻌﺘﺒﺮ ﺑﻤﺜﺎﺑﺔ ﻧﻔﻲ ﻭﺟﻮﺩ ﻣﺎﻳﺴﺘﺤﻖ ﺍﻹﻓﺼﺎﺡ ﻋﻨﻪ ﻭﻋﻠﻴﻪ ﺃﻭﻗﻊ‬
basis.
4- Failure to fill the weight and height information will result in refusal to cover
the cost of obesity surgery. ‫ ﻋﺪﻡ ﺗﻌﺒﺌﺔ ﺑﻴﺎﻧﺎﺕ ﺍﻟﻄﻮﻝ ﻭﺍﻟﻮﺯﻥ ﺳﻴﺆﺩﻱ ﺇﻟﻰ ﺭﻓﺾ ﺗﻐﻄﻴﺔ ﺗﻜﺎﻟﻴﻒ ﻋﻤﻠﻴﺔ ﺟﺮﺍﺣﺔ ﺍﻟﺴﻤﻨﺔ ﺍﻟﻤﻔﺮﻃﺔ‬-4

Entity's stamp ‫ﺧﺘﻢ ﺟﻬﺔ ﺍﻟﻌﻤﻞ‬ Insured Signature ‫ﺗﻮﻗﻴﻊ ﺍﻟﻤﻮﻇﻒ‬ Date ‫ﺍﻟﺘﺎﺭﻳﺦ‬
.. / .. / ....

New_Health_Insurance.rdf Page 31 of 39 V.20 13-DEC-2023 01:30 PM

 ‫ﻧﻤﻮﺫﺝ ﺍﻻﻓﺼﺎﺡ ﺍﻟﻄﺒﻲ ﺍﻟﻤﻮﺣﺪ‬
Unified Medical Declaration Form
Product Code: A-MLTH-2-C-08-014
Dear Insured: ‫ﻋﺰﻳﺰﻱ ﺍﻟﻤﺆﻣﻦ ﻟﻪ‬
Please Fill out the form correctly for the purpose of pricing and to ensured that you and your ‫ﻧﺄﻣﻞ ﻗﻴﺎﻣﻚ ﺑﺘﻌﺒﺌﺔ ﻫﺬﺍ ﺍﻟﻨﻤﻮﺫﺝ ﺑﺎﻟﺸﻜﻞ ﺍﻟﺼﺤﻴﺢ ﻟﻐﺮﺽ ﺍﻟﺘﺴﻌﻴﺮ ﻭﻟﻀﻤﺎﻥ ﺣﺼﻮﻟﻚ ﻭﺃﻓﺮﺍﺩ ﺃﺳﺮﺗﻚ ﻋﻠﻰ ﺧﺪﻣﺎﺕ‬
family receive health care services as required according to your unfied policy benefit ‫ﺍﻟﺮﻋﺎﻳﺔ ﺍﻟﺼﺤﻴﺔ ﺑﺎﻟﺸﻜﻞ ﺍﻟﻤﻄﻠﻮﺏ ﺣﺴﺐ ﻣﻨﺎﻓﻊ ﺍﻟﻮﺛﻴﻘﺔ ﺍﻟﻤﻮﺣﺪﺓ‬

Addition ‫ﺇﺿﺎﻓﺔ‬ New ‫ﺟﺪﻳﺪ‬ Type ‫ﻧﻮﻉ ﺍﻟﻄﻠﺐ‬

CR No 7011507360 ‫ﺍﻟﺴﺠﻞ ﺍﻟﺘﺠﺎﺭﻱ‬ Entity Name HADDAJ AL HIJAZ EST ‫ﺃﺳﻢ ﺍﻟﻤﻨﺸﺄﺓ‬
Mobile No 0551073264 ‫ﺭﻗﻢ ﺍﻟﺠﻮﺍﻝ‬ Khalid Hassan Ali Hussain ‫ﺍﺳﻢ ﺍﻟﻤﻮﻇﻒ‬
ID Number 2 1 9 1 6 8 3 5 3 7 ‫ﺭﻗﻢ ﺍﻟﻬﻮﻳﺔ‬
Male / ‫ﺫﻛﺮ‬ Yemen
Gender ‫ ﺍﻟﺠﻨﺲ‬Nationality ‫ ﺍﻟﺠﻨﺴﻴﺔ‬Marital status Married R ‫ﻣﺘﺰﻭﺝ‬ Single * ‫ﺃﻋﺰﺏ‬ ‫ﺍﻟﺤﺎﻟﺔ ﺍﻻﺟﺘﻤﺎﻋﻴﺔ‬
Please declare any of the below cases by marking P under the word Yes ‫ ﻓﻲ ﺍﻟﻤﺮﺑﻊ ﺗﺤﺖ ﻛﻠﻤﺔ ﻧﻌﻢ‬P ‫ﻳﺮﺟﻰ ﺍﻹﻓﺼﺎﺡ ﻋﻦ ﻭﺟﻮﺩ ﺃﻱ ﻣﻦ ﺍﻟﺤﺎﻻﺕ ﺍﺩﻧﺎﻩ ﺑﻮﺿﻊ ﺇﺷﺎﺭﺓ‬
"Below Undeclared Medical Case May Not Be Covered" No / ‫ﻻ‬ Yes / ‫ﻧﻌـﻢ‬ "‫"ﻟﻦ ﺗﺘﻢ ﺍﻟﺘﻐﻄﻴﺔ ﺍﻟﺘﺄﻣﻴﻨﻴﺔ ﻟﻠﺤﺎﻻﺕ ﺃﺩﻧﺎﻩ ﻓﻰ ﺣﺎﻝ ﻋﺪﻡ ﺍﻹﻓﺼﺎﺡ ﻋﻨﻬﺎ‬
Any hospital admission during last 12 months. ‫ ﺷﻬﺮ‬12 ‫ﻫﻞ ﺗﻢ ﺍﻟﺘﻨﻮﻳﻢ ﺑﺎﻟﻤﺴﺘﺸﻔﻰ ﺧﻼﻝ ﺃﺧﺮ‬
"Admission: registering as an admitted patient at the hospital until the following morning "
* * " ‫ ﺗﺴﺠﻴﻞ ﺍﻟﺸﺨﺺ ﺍﻟﻤﺆﻣﻦ ﻟﻪ ﻛﻤﺮﻳﺾ ﻣﻨﻮﻡ ﻓﻲ ﺍﻟﻤﺴﺘﺸﻔﻰ ﺣﺘﻰ ﺻﺒﺎﺡ ﺍﻟﻴﻮﻡ ﺍﻟﺘﺎﻟﻲ‬: ‫" ﺍﻟﺘﻨﻮﻳﻢ‬

Have you been diagnosed with any of the following chronic disease limited ‫ﻫﻞ ﺗﻢ ﺗﺸﺨﻴﺼﻚ ﺑﺄﻯ ﻣﻦ ﺍﻷﻣﺮﺍﺽ ﺍﻟﺘﺎﻟﻴﺔ ﻓﻘﻂ‬
to:Autism, listed Benign Tumor (Breast tumors, fibroid uterus, benign prostatic hyperplasia, ‫ﺃﻭﺭﺍﻡ ﺃﻭ‬,‫ﺗﻀﺨﻢ ﺍﻟﺒﺮﻭﺳﺘﺎﺗﺎ ﺍﻟﺤﻤﻴﺪ‬,‫ ﺃﻭﺭﺍﻡ ﺍﻟﺮﺣﻢ ﺍﻟﻠﻴﻔﻰ‬, ‫ﺍﻻﻭﺭﺍﻡ ﺍﻟﺤﻤﻴﺪﺓ ﺍﻟﺘﺎﻟﻴﺔ )ﺃﻭﺭﺍﻡ ﺍﻟﺜﺪﻯ‬,‫ﺍﻷﻭﺭﺍﻡ ﺍﻟﺴﺮﻃﺎﻧﻴﺔ‬,‫ﺍﻟﺘﻮﺣﺪ‬
thyroid goiter and parathyroid glands, live tumors, colon tumors). Malignant tumors, listed ‫ﺃﻣﺮﺍﺽ ﺍﻟﻘﻠﺐ ﺍﻟﺘﺎﻟﻴﺔ)ﺃﻣﺮﺍﺽ ﺷﺮﺍﻳﻴﻦ ﻭﺻﻤﺎﻣﺎﺕ ﺗﻀﺨﻢ ﺍﻟﻐﺪﺓ ﺍﻟﺪﺭﻗﻴﺔ‬, (‫ﺃﻭﺭﺍﻡ ﺍﻟﻘﻮﻟﻮﻥ‬, ‫ﻭﺃﻭﺭﺍﻡ ﺍﻻﻟﻜﺒﺪ‬,‫ﻭ ﺍﻟﺠﺎﺭ ﺍﻟﺪﺭﻗﻴﺔ‬
Cardiac diseases coronary and valve heart diseases, heart failure, cardiac fibrillation
myocardial infraction, heart clots). Chronic Hepatitis C. Gallstones Sever Kidney failure (stage
* * ‫ﺍﻻﻟﺘﻬﺎﺏ ﺍﻟﻜﺒﺪﻯ ﺍﻟﻔﻴﺮﻭﺳﻰ ﺍﻟﻤﺰﻣﻦ‬.( ‫ﺍﻟﺮﺟﻔﺎﻥ ﺍﻟﻘﻠﺒﻰ ﻭﺟﻠﻄﺎﺕ ﺍﻟﻘﻠﺐ‬, ‫ﻓﺸﻞ ﻋﻀﻠﺔ ﺍﻟﻘﻠﺐ‬, ‫ﺣﺼﻮﺍﺕ ﺍﻟﻤﺮﺍﺭﺓ ﺍﻟﻘﻠﺐ‬, ‫ﺝ ﻭﺳﻰ‬
,‫ ﺍﻟﺘﺮﺷﻴﺢ ﺍﻟﻜﻠﻮﻯ ﺃﻗﻞ ﻣﻦ‬,‫ ﺍﻟﻔﺸﻞ ﺍﻟﻜﻠﻮﻯﺍﻟﺸﺪﻳﺪ )ﺍﻟﻤﺮﺣﻠﺔ ﺍﻟﺨﺎﻣﺴﺔ ﻣﻦ ﺍﻣﺮﺍﺽ ﺍﻟﻜﻠﻰ ﺍﻟﺘﻰ ﺗﺴﺘﺪﻋﻰ ﺍﻟﻐﺴﻴﻞ ﺍﻟﻜﻠﻮﻯ‬15
5 Requiring dialysis, clearance of less tha 15 ml/ minute*). Urinary tract ‫ﻣﺮﺽ‬, ‫ﺩﻗﻴﻘﺔ(ﺣﺼﻮﺍﺕ ﺍﻟﻤﺴﺎﻟﻚ ﺍﻟﺒﻮﻟﻴﺔﺃﻣﺮﺍﺽ ﺍﻟﻤﻨﺎﻋﺔ ﺍﻟﺘﺎﻟﻴﺔ )ﺍﻟﺬﺋﺒﺔ ﺍﻟﺤﻤﺮﺍﺀﻭﺍﻟﺘﻬﺎﺏ ﺍﻟﻤﻔﺎﺻﻞ ﺍﻟﺮﻭﻣﺎﺗﻴﺰﻣﻴﺔﻭ ﺍﻟﺼﺪﻓﻴﺔ‬/‫ﻣﻞ‬
stones, hernias. Autoimmune disease (lupus, rheumatoid arthritis, psoriasis, Crohn's disease, ‫ﺍﻟﺘﻬﺎﺏ ﺍﻟﻘﻮﻟﻮﻥ ﺍﻟﺘﻘﺮﺣﻰ‬, ‫ﻛﺮﻭﻧﺰ‬,
ulcerative colitis,multiple sclerosis, celiac disease) ‫ﺣﺴﺎﺳﻴﺔ ﺍﻟﻘﻤﺢ‬, ‫ﺍﻟﺘﺼﻠﺐ ﺍﻟﻠﻮﻳﺤﻰ‬

Have you been diagnosed with any of the following congenital disorder or
hereditary diseases limited to: Cerebral palsy, Sickle cell disorder, Thalassemia, ‫ﻫﻞ ﺗﻢ ﺗﺸﺨﻴﺼﻚ ﺑﺄﻱ ﻣﻦ ﺍﻷﻣﺮﺍﺽ ﺍﻟﻮﺭﺍﺛﻴﺔ ﺃﻭ ﺍﻟﺘﺸﻮﻫﺎﺕ ﺍﻟﺨﻠﻘﻴﺔ ﺍﻟﺘﺎﻟﻴﺔ ﻓﻘﻂ‬
hemophilia, metabolic diseases, Hydrocephalus, spinal muscle atrophy, genital ‫ ﺿﻤﻮﺭ‬،‫ ﺃﺳﺘﺴﻘﺎﺀ ﺍﻟﺮﺃﺱ‬،‫ ﺃﻣﺮﺍﺽ ﺍﻟﺘﻤﺜﻴﻞ ﺍﻟﻐﺬﺍﺋﻲ‬،‫ ﺍﻟﻬﻴﻤﻮﻓﻴﻠﻴﺎ‬،‫ ﺍﻟﺘﻼﺳﻴﻤﻴﺎ‬،‫ﺍﺿﻄﺮﺍﺏ ﺍﻟﺨﻼﻳﺎ ﺍﻟﻤﻨﺠﻠﻴﺔ‬, ‫ﺍﻟﺸﻠﻞ ﺍﻟﺪﻣﺎﻏﻰ‬
malformations, chromosomal abnormalities. Gaucher's disease, G6PD Deficiency, cystic
fibrosis, hemochromatosis, Wilson disease. Polycystic Kidney Disease.
* * ‫ ﻣﺮﺽ ﺍﻟﺘﻜﺴﺮﺍﻟﻔﻮﻟﻰ‬،‫ ﻣﺮﺽ ﻏﻮﺷﺮ‬،‫ ﺃﻣﺮﺍﺽ ﺍﻟﻜﺮﻭﻣﻮﺳﻮﻣﺎﺕ‬،‫ ﺗﺸﻮﻫﺎﺕ ﺍﻷﻋﻀﺎﺀ ﺍﻟﺘﻨﺎﺳﻠﻴﺔ‬،‫ﺍﻟﻌﻀﻼﺕ ﺍﻟﺸﻮﻛﻲ‬
‫ﺗﻜﻴﺲ‬,‫ﻣﺮﺽ ﻭﻳﻠﺴﻮﻥ‬, (‫ ﻣﺮﺽ ﺗﻜﺪﺱ ﺍﻟﺤﺪﻳﺪ )ﻫﻴﻤﻮﻛﺮﻭﻣﺎﺗﻮﺳﻴﺲ‬،‫( ﺍﻟﺘﻠﻴﻒ ﺍﻟﻜﻴﺴﻲ ﻟﻠﺮﺋﺔ‬G6PD)
‫ﺍﻟﻜﻠﻴﺘﻴﻦ ﺍﻟﺨﻠﻔﻰ ﺍﻟﻮﺭﺍﺋﻰ‬

Have you been diagnosed with any of following eye diseases limited to: ،‫ ﻣﻴﺎﺓ ﺯﺭﻗﺎﺀ‬،‫ ﻣﻴﺎﺓ ﺑﻴﻀﺎﺀ‬:‫ﻫﻞ ﺗﻢ ﺗﺸﺨﻴﺼﻚ ﺑﺄﻱ ﻣﻦ ﺃﻣﺮﺍﺽ ﺍﻟﻌﻴﻦ ﺍﻟﺘﺎﻟﻴﺔ ﻓﻘﻂ‬
Cataract, Glaucoma, Retinal diseases. * * ‫ﺃﻣﺮﺍﺽ ﺍﻟﺸﺒﻜﻴﺔ‬
Have you been diagnosed with any of the following bone diseases limited ‫ ﺍﻹﻧﺰﻻﻕ ﺍﻟﻐﻀﺮﻭﻓﻲ‬:‫ﻫﻞ ﺗﻢ ﺗﺸﺨﻴﺼﻚ ﺑﺄﻱ ﻣﻦ ﺃﻣﺮﺍﺽ ﺍﻟﻌﻈﺎﻡ ﺍﻟﺘﺎﻟﻴﺔ ﻓﻘﻂ‬
to:Vertebral disc prolapse (moderate or severe), Scoliosis (moderate or severe)**, or ligament
tears, osteoarthritis (moderate or severe )
* * ‫ﺗﻤﺰﻕ ﺍﻷﺭﺑﻄﺔ‬،‫ﺍﻟﺘﻬﺎﺏ ﺍﻟﻤﻔﺎﺻﻞ‬،‫ﺇﻧﺤﺮﺍﻑ ﺍﻟﻌﻤﻮﺩ ﺍﻟﻔﻘﺮﻱ‬,‫ﺍﻟﺪﻳﺴﻚ‬

Pregnant Female Only ‫ﻟﻸﻧﺜﻰ ﺍﻟﺤﺎﻣﻞ ﻓﻘﻂ‬

‫ﺣﻤﻞ ﺣﺎﻟﻲ ﺟﻨﻴﻦ ﻭﺍﺣﺪ‬
Current Single Pregnancy
* *
‫ﺣﻤﻞ ﺣﺎﻟﻲ ﻣﻊ ﻗﻴﺼﺮﻳﺔ ﺳﺎﺑﻘﺔ‬
Current Single Pregnancy with Previous CS Delivery
* *
‫ﺣﻤﻞ ﺣﺎﻟﻲ ﻣﺘﻌﺪﺩ ﺍﻷﺟﻨﺔ‬
Current Multiple Pregnancy
* *
Expected delivery date .. / .. / .... ‫ﺗﺎﺭﻳﺦ ﺍﻟﻮﻻﺩﺓ ﺍﻟﻤﺘﻮﻗﻊ‬
Employee and dependents details that need to be added ‫ﺑﻴﺎﻧﺎﺕ ﺍﻟﻤﻮﻇﻒ ﻭﺃﻓﺮﺍﺩ ﺍﻟﻌﺎﺋﻠﺔ ﺍﻟﻤﺮﺍﺩ ﺇﺿﺎﻓﺘﻬﻢ‬
In case of a yes answer above, please declare the case in the table below ‫ ﺍﻟﺮﺟﺎﺀ ﺫﻛﺮ ﺍﻟﺤﺎﻟﺔ ﻓﻲ ﺍﻟﺠﺪﻭﻝ ﺃﺩﻧﺎﻩ‬،‫ﻓﻲ ﺣﺎﻟﺔ ﺍﻹﺟﺎﺑﺔ ﺑﻨﻌﻢ ﺃﻋﻼﻩ‬
‫ﺇﺳﻢ ﻣﻘﺪﻡ ﺍﻟﺨﺪﻣﺔ‬ ‫ﺍﻟﺤﺎﻟﺔ‬ ‫ﺭﻗﻢ ﺍﻟﺠﻮﺍﻝ‬ ‫ﺍﻟﻄﻮﻝ‬ ‫ﺍﻟﻮﺯﻥ‬ ‫ﺭﻗﻢ ﺍﻟﻬﻮﻳﺔ‬ ‫ﺍﻟﻘﺮﺍﺑﺔ‬ ‫ﺍﻟﺠﻨﺲ‬ ‫ ﺃﻓﺮﺍﺩ ﺍﻟﻌﺎﺋﻠﺔ‬/ ‫ﺍﺳﻢ ﺍﻟﻤﻮﻇﻒ‬ ‫ﻡ‬
2191683537 Employee Male / ‫ ﺫﻛﺮ‬Khalid Hassan Ali Hussain 1
2
3
4
5
Undertakings : ‫ﺍﻹﻗﺮﺍﺭ ﻭﺍﻟﺘﻔﻮﻳﺾ‬
1- I hereby undertake that all the above information is correct and the acceptance of my ‫ﻭﺍﻟﻤﻌﻠﻮﻣﺎﺕ ﺍﻟﻤﺬﻛﻮﺭﺓ ﺃﻋﻼﻩ ﻛﺎﻣﻠﺔ ﻭﺻﺤﻴﺤﺔ ﻭﺑﻨﺎﺀ ﻋﻠﻴﻪ ﻓﺈﻥ ﻗﺒﻮﻝ ﺍﻟﻄﻠﺐ ﺳﻴﺘﻢ‬: ‫ ﺃﻗﺮ ﺃﻥ ﺍﻟﺒﻴﺎﻧﺎﺕ‬-1
enrollment will be on the basis of such information and that Malath Cooperative Insurance ‫ﻋﻠﻰ ﺃﺳﺎﺱ ﻫﺬﻩ ﺍﻟﺒﻴﺎﻧﺎﺕ ﻭﺃﻥ ﺷﺮﻛﺔ ﻣﻼﺫ ﻟﻠﺘﺄﻣﻴﻦ ﺍﻟﺘﻌﺎﻭﻧﻲ ﻟﻬﺎ ﺍﻟﺤﻖ ﻓﻲ ﺍﻻﺗﺼﺎﻝ ﺑﺎﻟﻤﺴﺘﺸﻔﻴﺎﺕ ﺍﻟﺘﻲ‬
Company has the right to contact the hospital(s) I deal with to collect any ‫ﺃﺗﻌﺎﻣﻞ ﻣﻌﻬﺎ ﻟﺘﺰﻭﻳﺪﻫﺎ ﺑﺄﻱ ﻣﻌﻠﻮﻣﺎﺕ ﻃﺒﻴﺔ ﻗﺪ ﺗﺤﺘﺎﺝ ﺇﻟﻴﻬﺎ ﻟﺘﻘﻴﻴﻢ ﺍﻟﻤﺨﺎﻃﺮ‬
medical information needed to assess the risk(s).

2- I agree that Malath Cooperative Insurance Company has the right to reject the ‫ ﺃﻭﺍﻓﻖ ﻋﻠﻰ ﺃﺣﻘﻴﺔ ﺷﺮﻛﺔ ﻣﻼﺫ ﻟﻠﺘﺄﻣﻴﻦ ﻓﻲ ﺭﻓﺾ ﺍﻟﻤﻄﺎﻟﺒﺔ ﺃﻭ ﺍﻟﺘﻐﻄﻴﺔ ﻛﻠﻴﺎ ﻋﻨﺪ ﻋﺪﻡ ﺍﻹﻓﺼﺎﺡ ﻋﻦ ﻭﺟﻮﺩ ﺃﻱ ﻣﻦ ﺍﻟﺤﺎﻻﺕ‬-2
coverage/claims in full in case of no declaration of any cases prior to the contractual date or ‫ﺍﻟﻤﺬﻛﻮﺭﺓ ﺃﻋﻼﻩ ﺍﻟﺘﻲ ﻧﺸﺄﺕ ﻗﺒﻞ ﺗﺎﺭﻳﺦ ﺍﻟﺘﻌﺎﻗﺪ ﺃﻭ ﻗﺒﻞ ﺗﺴﺠﻴﻞ ﺃﻭ ﺇﺿﺎﻓﺔ ﻋﻀﻮ ﺧﻼﻝ ﻓﺘﺮﺓ ﺳﺮﻳﺎﻥ ﺍﻟﻌﻘﺪ‬
before enrolling or adding a new member during the contract.

3- I hereby confirm reading and understanding all points presented in this form and I agree that ‫ ﺃﻗﺮﺑﺄﻧﻲ ﻗﺪ ﻗﺮﺃﺕ ﻭﻓﻬﻤﺖ ﺟﻤﻴﻊ ﻣﺎ ﺟﺎﺀ ﻓﻲ ﻫﺬﺍ ﺍﻟﻨﻤﻮﺫﺝ ﻛﻤﺎ ﺃﺗﻌﻬﺪ ﺑﺄﻥ ﻋﺪﻡ ﺇﺷﺎﺭﺗﻲ ﺃﻣﺎﻡ ﺃﻱ ﻣﻦ‬-3
not marking any case is understood as “Nothing requires declaration” and I sign on these ‫ﺍﻟﺤﺎﻻﺕ ﺍﻟﻤﺬﻛﻮﺭﺓ ﺃﻋﻼﻩ ﻳﻌﺘﺒﺮ ﺑﻤﺜﺎﺑﺔ ﻧﻔﻲ ﻭﺟﻮﺩ ﻣﺎﻳﺴﺘﺤﻖ ﺍﻹﻓﺼﺎﺡ ﻋﻨﻪ ﻭﻋﻠﻴﻪ ﺃﻭﻗﻊ‬
basis.
4- Failure to fill the weight and height information will result in refusal to cover
the cost of obesity surgery. ‫ ﻋﺪﻡ ﺗﻌﺒﺌﺔ ﺑﻴﺎﻧﺎﺕ ﺍﻟﻄﻮﻝ ﻭﺍﻟﻮﺯﻥ ﺳﻴﺆﺩﻱ ﺇﻟﻰ ﺭﻓﺾ ﺗﻐﻄﻴﺔ ﺗﻜﺎﻟﻴﻒ ﻋﻤﻠﻴﺔ ﺟﺮﺍﺣﺔ ﺍﻟﺴﻤﻨﺔ ﺍﻟﻤﻔﺮﻃﺔ‬-4

Entity's stamp ‫ﺧﺘﻢ ﺟﻬﺔ ﺍﻟﻌﻤﻞ‬ Insured Signature ‫ﺗﻮﻗﻴﻊ ﺍﻟﻤﻮﻇﻒ‬ Date ‫ﺍﻟﺘﺎﺭﻳﺦ‬
.. / .. / ....

New_Health_Insurance.rdf Page 32 of 39 V.20 13-DEC-2023 01:30 PM

 ‫ﻧﻤﻮﺫﺝ ﺍﻻﻓﺼﺎﺡ ﺍﻟﻄﺒﻲ ﺍﻟﻤﻮﺣﺪ‬
Unified Medical Declaration Form
Product Code: A-MLTH-2-C-08-014
Dear Insured: ‫ﻋﺰﻳﺰﻱ ﺍﻟﻤﺆﻣﻦ ﻟﻪ‬
Please Fill out the form correctly for the purpose of pricing and to ensured that you and your ‫ﻧﺄﻣﻞ ﻗﻴﺎﻣﻚ ﺑﺘﻌﺒﺌﺔ ﻫﺬﺍ ﺍﻟﻨﻤﻮﺫﺝ ﺑﺎﻟﺸﻜﻞ ﺍﻟﺼﺤﻴﺢ ﻟﻐﺮﺽ ﺍﻟﺘﺴﻌﻴﺮ ﻭﻟﻀﻤﺎﻥ ﺣﺼﻮﻟﻚ ﻭﺃﻓﺮﺍﺩ ﺃﺳﺮﺗﻚ ﻋﻠﻰ ﺧﺪﻣﺎﺕ‬
family receive health care services as required according to your unfied policy benefit ‫ﺍﻟﺮﻋﺎﻳﺔ ﺍﻟﺼﺤﻴﺔ ﺑﺎﻟﺸﻜﻞ ﺍﻟﻤﻄﻠﻮﺏ ﺣﺴﺐ ﻣﻨﺎﻓﻊ ﺍﻟﻮﺛﻴﻘﺔ ﺍﻟﻤﻮﺣﺪﺓ‬

Addition ‫ﺇﺿﺎﻓﺔ‬ New ‫ﺟﺪﻳﺪ‬ Type ‫ﻧﻮﻉ ﺍﻟﻄﻠﺐ‬

CR No 7011507360 ‫ﺍﻟﺴﺠﻞ ﺍﻟﺘﺠﺎﺭﻱ‬ Entity Name HADDAJ AL HIJAZ EST ‫ﺃﺳﻢ ﺍﻟﻤﻨﺸﺄﺓ‬
Mobile No 0556362602 ‫ﺭﻗﻢ ﺍﻟﺠﻮﺍﻝ‬ Anwar Hossain - - Abdulrashid ‫ﺍﺳﻢ ﺍﻟﻤﻮﻇﻒ‬
ID Number 2 2 0 2 5 4 6 2 9 3 ‫ﺭﻗﻢ ﺍﻟﻬﻮﻳﺔ‬
Male / ‫ﺫﻛﺮ‬ Bangladesh
Gender ‫ ﺍﻟﺠﻨﺲ‬Nationality ‫ ﺍﻟﺠﻨﺴﻴﺔ‬Marital status Married * ‫ﻣﺘﺰﻭﺝ‬ Single R ‫ﺃﻋﺰﺏ‬ ‫ﺍﻟﺤﺎﻟﺔ ﺍﻻﺟﺘﻤﺎﻋﻴﺔ‬
Please declare any of the below cases by marking P under the word Yes ‫ ﻓﻲ ﺍﻟﻤﺮﺑﻊ ﺗﺤﺖ ﻛﻠﻤﺔ ﻧﻌﻢ‬P ‫ﻳﺮﺟﻰ ﺍﻹﻓﺼﺎﺡ ﻋﻦ ﻭﺟﻮﺩ ﺃﻱ ﻣﻦ ﺍﻟﺤﺎﻻﺕ ﺍﺩﻧﺎﻩ ﺑﻮﺿﻊ ﺇﺷﺎﺭﺓ‬
"Below Undeclared Medical Case May Not Be Covered" No / ‫ﻻ‬ Yes / ‫ﻧﻌـﻢ‬ "‫"ﻟﻦ ﺗﺘﻢ ﺍﻟﺘﻐﻄﻴﺔ ﺍﻟﺘﺄﻣﻴﻨﻴﺔ ﻟﻠﺤﺎﻻﺕ ﺃﺩﻧﺎﻩ ﻓﻰ ﺣﺎﻝ ﻋﺪﻡ ﺍﻹﻓﺼﺎﺡ ﻋﻨﻬﺎ‬
Any hospital admission during last 12 months. ‫ ﺷﻬﺮ‬12 ‫ﻫﻞ ﺗﻢ ﺍﻟﺘﻨﻮﻳﻢ ﺑﺎﻟﻤﺴﺘﺸﻔﻰ ﺧﻼﻝ ﺃﺧﺮ‬
"Admission: registering as an admitted patient at the hospital until the following morning "
* * " ‫ ﺗﺴﺠﻴﻞ ﺍﻟﺸﺨﺺ ﺍﻟﻤﺆﻣﻦ ﻟﻪ ﻛﻤﺮﻳﺾ ﻣﻨﻮﻡ ﻓﻲ ﺍﻟﻤﺴﺘﺸﻔﻰ ﺣﺘﻰ ﺻﺒﺎﺡ ﺍﻟﻴﻮﻡ ﺍﻟﺘﺎﻟﻲ‬: ‫" ﺍﻟﺘﻨﻮﻳﻢ‬

Have you been diagnosed with any of the following chronic disease limited ‫ﻫﻞ ﺗﻢ ﺗﺸﺨﻴﺼﻚ ﺑﺄﻯ ﻣﻦ ﺍﻷﻣﺮﺍﺽ ﺍﻟﺘﺎﻟﻴﺔ ﻓﻘﻂ‬
to:Autism, listed Benign Tumor (Breast tumors, fibroid uterus, benign prostatic hyperplasia, ‫ﺃﻭﺭﺍﻡ ﺃﻭ‬,‫ﺗﻀﺨﻢ ﺍﻟﺒﺮﻭﺳﺘﺎﺗﺎ ﺍﻟﺤﻤﻴﺪ‬,‫ ﺃﻭﺭﺍﻡ ﺍﻟﺮﺣﻢ ﺍﻟﻠﻴﻔﻰ‬, ‫ﺍﻻﻭﺭﺍﻡ ﺍﻟﺤﻤﻴﺪﺓ ﺍﻟﺘﺎﻟﻴﺔ )ﺃﻭﺭﺍﻡ ﺍﻟﺜﺪﻯ‬,‫ﺍﻷﻭﺭﺍﻡ ﺍﻟﺴﺮﻃﺎﻧﻴﺔ‬,‫ﺍﻟﺘﻮﺣﺪ‬
thyroid goiter and parathyroid glands, live tumors, colon tumors). Malignant tumors, listed ‫ﺃﻣﺮﺍﺽ ﺍﻟﻘﻠﺐ ﺍﻟﺘﺎﻟﻴﺔ)ﺃﻣﺮﺍﺽ ﺷﺮﺍﻳﻴﻦ ﻭﺻﻤﺎﻣﺎﺕ ﺗﻀﺨﻢ ﺍﻟﻐﺪﺓ ﺍﻟﺪﺭﻗﻴﺔ‬, (‫ﺃﻭﺭﺍﻡ ﺍﻟﻘﻮﻟﻮﻥ‬, ‫ﻭﺃﻭﺭﺍﻡ ﺍﻻﻟﻜﺒﺪ‬,‫ﻭ ﺍﻟﺠﺎﺭ ﺍﻟﺪﺭﻗﻴﺔ‬
Cardiac diseases coronary and valve heart diseases, heart failure, cardiac fibrillation
myocardial infraction, heart clots). Chronic Hepatitis C. Gallstones Sever Kidney failure (stage
* * ‫ﺍﻻﻟﺘﻬﺎﺏ ﺍﻟﻜﺒﺪﻯ ﺍﻟﻔﻴﺮﻭﺳﻰ ﺍﻟﻤﺰﻣﻦ‬.( ‫ﺍﻟﺮﺟﻔﺎﻥ ﺍﻟﻘﻠﺒﻰ ﻭﺟﻠﻄﺎﺕ ﺍﻟﻘﻠﺐ‬, ‫ﻓﺸﻞ ﻋﻀﻠﺔ ﺍﻟﻘﻠﺐ‬, ‫ﺣﺼﻮﺍﺕ ﺍﻟﻤﺮﺍﺭﺓ ﺍﻟﻘﻠﺐ‬, ‫ﺝ ﻭﺳﻰ‬
,‫ ﺍﻟﺘﺮﺷﻴﺢ ﺍﻟﻜﻠﻮﻯ ﺃﻗﻞ ﻣﻦ‬,‫ ﺍﻟﻔﺸﻞ ﺍﻟﻜﻠﻮﻯﺍﻟﺸﺪﻳﺪ )ﺍﻟﻤﺮﺣﻠﺔ ﺍﻟﺨﺎﻣﺴﺔ ﻣﻦ ﺍﻣﺮﺍﺽ ﺍﻟﻜﻠﻰ ﺍﻟﺘﻰ ﺗﺴﺘﺪﻋﻰ ﺍﻟﻐﺴﻴﻞ ﺍﻟﻜﻠﻮﻯ‬15
5 Requiring dialysis, clearance of less tha 15 ml/ minute*). Urinary tract ‫ﻣﺮﺽ‬, ‫ﺩﻗﻴﻘﺔ(ﺣﺼﻮﺍﺕ ﺍﻟﻤﺴﺎﻟﻚ ﺍﻟﺒﻮﻟﻴﺔﺃﻣﺮﺍﺽ ﺍﻟﻤﻨﺎﻋﺔ ﺍﻟﺘﺎﻟﻴﺔ )ﺍﻟﺬﺋﺒﺔ ﺍﻟﺤﻤﺮﺍﺀﻭﺍﻟﺘﻬﺎﺏ ﺍﻟﻤﻔﺎﺻﻞ ﺍﻟﺮﻭﻣﺎﺗﻴﺰﻣﻴﺔﻭ ﺍﻟﺼﺪﻓﻴﺔ‬/‫ﻣﻞ‬
stones, hernias. Autoimmune disease (lupus, rheumatoid arthritis, psoriasis, Crohn's disease, ‫ﺍﻟﺘﻬﺎﺏ ﺍﻟﻘﻮﻟﻮﻥ ﺍﻟﺘﻘﺮﺣﻰ‬, ‫ﻛﺮﻭﻧﺰ‬,
ulcerative colitis,multiple sclerosis, celiac disease) ‫ﺣﺴﺎﺳﻴﺔ ﺍﻟﻘﻤﺢ‬, ‫ﺍﻟﺘﺼﻠﺐ ﺍﻟﻠﻮﻳﺤﻰ‬

Have you been diagnosed with any of the following congenital disorder or
hereditary diseases limited to: Cerebral palsy, Sickle cell disorder, Thalassemia, ‫ﻫﻞ ﺗﻢ ﺗﺸﺨﻴﺼﻚ ﺑﺄﻱ ﻣﻦ ﺍﻷﻣﺮﺍﺽ ﺍﻟﻮﺭﺍﺛﻴﺔ ﺃﻭ ﺍﻟﺘﺸﻮﻫﺎﺕ ﺍﻟﺨﻠﻘﻴﺔ ﺍﻟﺘﺎﻟﻴﺔ ﻓﻘﻂ‬
hemophilia, metabolic diseases, Hydrocephalus, spinal muscle atrophy, genital ‫ ﺿﻤﻮﺭ‬،‫ ﺃﺳﺘﺴﻘﺎﺀ ﺍﻟﺮﺃﺱ‬،‫ ﺃﻣﺮﺍﺽ ﺍﻟﺘﻤﺜﻴﻞ ﺍﻟﻐﺬﺍﺋﻲ‬،‫ ﺍﻟﻬﻴﻤﻮﻓﻴﻠﻴﺎ‬،‫ ﺍﻟﺘﻼﺳﻴﻤﻴﺎ‬،‫ﺍﺿﻄﺮﺍﺏ ﺍﻟﺨﻼﻳﺎ ﺍﻟﻤﻨﺠﻠﻴﺔ‬, ‫ﺍﻟﺸﻠﻞ ﺍﻟﺪﻣﺎﻏﻰ‬
malformations, chromosomal abnormalities. Gaucher's disease, G6PD Deficiency, cystic
fibrosis, hemochromatosis, Wilson disease. Polycystic Kidney Disease.
* * ‫ ﻣﺮﺽ ﺍﻟﺘﻜﺴﺮﺍﻟﻔﻮﻟﻰ‬،‫ ﻣﺮﺽ ﻏﻮﺷﺮ‬،‫ ﺃﻣﺮﺍﺽ ﺍﻟﻜﺮﻭﻣﻮﺳﻮﻣﺎﺕ‬،‫ ﺗﺸﻮﻫﺎﺕ ﺍﻷﻋﻀﺎﺀ ﺍﻟﺘﻨﺎﺳﻠﻴﺔ‬،‫ﺍﻟﻌﻀﻼﺕ ﺍﻟﺸﻮﻛﻲ‬
‫ﺗﻜﻴﺲ‬,‫ﻣﺮﺽ ﻭﻳﻠﺴﻮﻥ‬, (‫ ﻣﺮﺽ ﺗﻜﺪﺱ ﺍﻟﺤﺪﻳﺪ )ﻫﻴﻤﻮﻛﺮﻭﻣﺎﺗﻮﺳﻴﺲ‬،‫( ﺍﻟﺘﻠﻴﻒ ﺍﻟﻜﻴﺴﻲ ﻟﻠﺮﺋﺔ‬G6PD)
‫ﺍﻟﻜﻠﻴﺘﻴﻦ ﺍﻟﺨﻠﻔﻰ ﺍﻟﻮﺭﺍﺋﻰ‬

Have you been diagnosed with any of following eye diseases limited to: ،‫ ﻣﻴﺎﺓ ﺯﺭﻗﺎﺀ‬،‫ ﻣﻴﺎﺓ ﺑﻴﻀﺎﺀ‬:‫ﻫﻞ ﺗﻢ ﺗﺸﺨﻴﺼﻚ ﺑﺄﻱ ﻣﻦ ﺃﻣﺮﺍﺽ ﺍﻟﻌﻴﻦ ﺍﻟﺘﺎﻟﻴﺔ ﻓﻘﻂ‬
Cataract, Glaucoma, Retinal diseases. * * ‫ﺃﻣﺮﺍﺽ ﺍﻟﺸﺒﻜﻴﺔ‬
Have you been diagnosed with any of the following bone diseases limited ‫ ﺍﻹﻧﺰﻻﻕ ﺍﻟﻐﻀﺮﻭﻓﻲ‬:‫ﻫﻞ ﺗﻢ ﺗﺸﺨﻴﺼﻚ ﺑﺄﻱ ﻣﻦ ﺃﻣﺮﺍﺽ ﺍﻟﻌﻈﺎﻡ ﺍﻟﺘﺎﻟﻴﺔ ﻓﻘﻂ‬
to:Vertebral disc prolapse (moderate or severe), Scoliosis (moderate or severe)**, or ligament
tears, osteoarthritis (moderate or severe )
* * ‫ﺗﻤﺰﻕ ﺍﻷﺭﺑﻄﺔ‬،‫ﺍﻟﺘﻬﺎﺏ ﺍﻟﻤﻔﺎﺻﻞ‬،‫ﺇﻧﺤﺮﺍﻑ ﺍﻟﻌﻤﻮﺩ ﺍﻟﻔﻘﺮﻱ‬,‫ﺍﻟﺪﻳﺴﻚ‬

Pregnant Female Only ‫ﻟﻸﻧﺜﻰ ﺍﻟﺤﺎﻣﻞ ﻓﻘﻂ‬

‫ﺣﻤﻞ ﺣﺎﻟﻲ ﺟﻨﻴﻦ ﻭﺍﺣﺪ‬
Current Single Pregnancy
* *
‫ﺣﻤﻞ ﺣﺎﻟﻲ ﻣﻊ ﻗﻴﺼﺮﻳﺔ ﺳﺎﺑﻘﺔ‬
Current Single Pregnancy with Previous CS Delivery
* *
‫ﺣﻤﻞ ﺣﺎﻟﻲ ﻣﺘﻌﺪﺩ ﺍﻷﺟﻨﺔ‬
Current Multiple Pregnancy
* *
Expected delivery date .. / .. / .... ‫ﺗﺎﺭﻳﺦ ﺍﻟﻮﻻﺩﺓ ﺍﻟﻤﺘﻮﻗﻊ‬
Employee and dependents details that need to be added ‫ﺑﻴﺎﻧﺎﺕ ﺍﻟﻤﻮﻇﻒ ﻭﺃﻓﺮﺍﺩ ﺍﻟﻌﺎﺋﻠﺔ ﺍﻟﻤﺮﺍﺩ ﺇﺿﺎﻓﺘﻬﻢ‬
In case of a yes answer above, please declare the case in the table below ‫ ﺍﻟﺮﺟﺎﺀ ﺫﻛﺮ ﺍﻟﺤﺎﻟﺔ ﻓﻲ ﺍﻟﺠﺪﻭﻝ ﺃﺩﻧﺎﻩ‬،‫ﻓﻲ ﺣﺎﻟﺔ ﺍﻹﺟﺎﺑﺔ ﺑﻨﻌﻢ ﺃﻋﻼﻩ‬
‫ﺇﺳﻢ ﻣﻘﺪﻡ ﺍﻟﺨﺪﻣﺔ‬ ‫ﺍﻟﺤﺎﻟﺔ‬ ‫ﺭﻗﻢ ﺍﻟﺠﻮﺍﻝ‬ ‫ﺍﻟﻄﻮﻝ‬ ‫ﺍﻟﻮﺯﻥ‬ ‫ﺭﻗﻢ ﺍﻟﻬﻮﻳﺔ‬ ‫ﺍﻟﻘﺮﺍﺑﺔ‬ ‫ﺍﻟﺠﻨﺲ‬ ‫ ﺃﻓﺮﺍﺩ ﺍﻟﻌﺎﺋﻠﺔ‬/ ‫ﺍﺳﻢ ﺍﻟﻤﻮﻇﻒ‬ ‫ﻡ‬
2202546293 Employee Male / ‫ ﺫﻛﺮ‬Anwar Hossain - - Abdulrashid 1
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Undertakings : ‫ﺍﻹﻗﺮﺍﺭ ﻭﺍﻟﺘﻔﻮﻳﺾ‬
1- I hereby undertake that all the above information is correct and the acceptance of my ‫ﻭﺍﻟﻤﻌﻠﻮﻣﺎﺕ ﺍﻟﻤﺬﻛﻮﺭﺓ ﺃﻋﻼﻩ ﻛﺎﻣﻠﺔ ﻭﺻﺤﻴﺤﺔ ﻭﺑﻨﺎﺀ ﻋﻠﻴﻪ ﻓﺈﻥ ﻗﺒﻮﻝ ﺍﻟﻄﻠﺐ ﺳﻴﺘﻢ‬: ‫ ﺃﻗﺮ ﺃﻥ ﺍﻟﺒﻴﺎﻧﺎﺕ‬-1
enrollment will be on the basis of such information and that Malath Cooperative Insurance ‫ﻋﻠﻰ ﺃﺳﺎﺱ ﻫﺬﻩ ﺍﻟﺒﻴﺎﻧﺎﺕ ﻭﺃﻥ ﺷﺮﻛﺔ ﻣﻼﺫ ﻟﻠﺘﺄﻣﻴﻦ ﺍﻟﺘﻌﺎﻭﻧﻲ ﻟﻬﺎ ﺍﻟﺤﻖ ﻓﻲ ﺍﻻﺗﺼﺎﻝ ﺑﺎﻟﻤﺴﺘﺸﻔﻴﺎﺕ ﺍﻟﺘﻲ‬
Company has the right to contact the hospital(s) I deal with to collect any ‫ﺃﺗﻌﺎﻣﻞ ﻣﻌﻬﺎ ﻟﺘﺰﻭﻳﺪﻫﺎ ﺑﺄﻱ ﻣﻌﻠﻮﻣﺎﺕ ﻃﺒﻴﺔ ﻗﺪ ﺗﺤﺘﺎﺝ ﺇﻟﻴﻬﺎ ﻟﺘﻘﻴﻴﻢ ﺍﻟﻤﺨﺎﻃﺮ‬
medical information needed to assess the risk(s).

2- I agree that Malath Cooperative Insurance Company has the right to reject the ‫ ﺃﻭﺍﻓﻖ ﻋﻠﻰ ﺃﺣﻘﻴﺔ ﺷﺮﻛﺔ ﻣﻼﺫ ﻟﻠﺘﺄﻣﻴﻦ ﻓﻲ ﺭﻓﺾ ﺍﻟﻤﻄﺎﻟﺒﺔ ﺃﻭ ﺍﻟﺘﻐﻄﻴﺔ ﻛﻠﻴﺎ ﻋﻨﺪ ﻋﺪﻡ ﺍﻹﻓﺼﺎﺡ ﻋﻦ ﻭﺟﻮﺩ ﺃﻱ ﻣﻦ ﺍﻟﺤﺎﻻﺕ‬-2
coverage/claims in full in case of no declaration of any cases prior to the contractual date or ‫ﺍﻟﻤﺬﻛﻮﺭﺓ ﺃﻋﻼﻩ ﺍﻟﺘﻲ ﻧﺸﺄﺕ ﻗﺒﻞ ﺗﺎﺭﻳﺦ ﺍﻟﺘﻌﺎﻗﺪ ﺃﻭ ﻗﺒﻞ ﺗﺴﺠﻴﻞ ﺃﻭ ﺇﺿﺎﻓﺔ ﻋﻀﻮ ﺧﻼﻝ ﻓﺘﺮﺓ ﺳﺮﻳﺎﻥ ﺍﻟﻌﻘﺪ‬
before enrolling or adding a new member during the contract.

3- I hereby confirm reading and understanding all points presented in this form and I agree that ‫ ﺃﻗﺮﺑﺄﻧﻲ ﻗﺪ ﻗﺮﺃﺕ ﻭﻓﻬﻤﺖ ﺟﻤﻴﻊ ﻣﺎ ﺟﺎﺀ ﻓﻲ ﻫﺬﺍ ﺍﻟﻨﻤﻮﺫﺝ ﻛﻤﺎ ﺃﺗﻌﻬﺪ ﺑﺄﻥ ﻋﺪﻡ ﺇﺷﺎﺭﺗﻲ ﺃﻣﺎﻡ ﺃﻱ ﻣﻦ‬-3
not marking any case is understood as “Nothing requires declaration” and I sign on these ‫ﺍﻟﺤﺎﻻﺕ ﺍﻟﻤﺬﻛﻮﺭﺓ ﺃﻋﻼﻩ ﻳﻌﺘﺒﺮ ﺑﻤﺜﺎﺑﺔ ﻧﻔﻲ ﻭﺟﻮﺩ ﻣﺎﻳﺴﺘﺤﻖ ﺍﻹﻓﺼﺎﺡ ﻋﻨﻪ ﻭﻋﻠﻴﻪ ﺃﻭﻗﻊ‬
basis.
4- Failure to fill the weight and height information will result in refusal to cover
the cost of obesity surgery. ‫ ﻋﺪﻡ ﺗﻌﺒﺌﺔ ﺑﻴﺎﻧﺎﺕ ﺍﻟﻄﻮﻝ ﻭﺍﻟﻮﺯﻥ ﺳﻴﺆﺩﻱ ﺇﻟﻰ ﺭﻓﺾ ﺗﻐﻄﻴﺔ ﺗﻜﺎﻟﻴﻒ ﻋﻤﻠﻴﺔ ﺟﺮﺍﺣﺔ ﺍﻟﺴﻤﻨﺔ ﺍﻟﻤﻔﺮﻃﺔ‬-4

Entity's stamp ‫ﺧﺘﻢ ﺟﻬﺔ ﺍﻟﻌﻤﻞ‬ Insured Signature ‫ﺗﻮﻗﻴﻊ ﺍﻟﻤﻮﻇﻒ‬ Date ‫ﺍﻟﺘﺎﺭﻳﺦ‬
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New_Health_Insurance.rdf Page 33 of 39 V.20 13-DEC-2023 01:30 PM

 ‫ﻧﻤﻮﺫﺝ ﺍﻻﻓﺼﺎﺡ ﺍﻟﻄﺒﻲ ﺍﻟﻤﻮﺣﺪ‬
Unified Medical Declaration Form
Product Code: A-MLTH-2-C-08-014
Dear Insured: ‫ﻋﺰﻳﺰﻱ ﺍﻟﻤﺆﻣﻦ ﻟﻪ‬
Please Fill out the form correctly for the purpose of pricing and to ensured that you and your ‫ﻧﺄﻣﻞ ﻗﻴﺎﻣﻚ ﺑﺘﻌﺒﺌﺔ ﻫﺬﺍ ﺍﻟﻨﻤﻮﺫﺝ ﺑﺎﻟﺸﻜﻞ ﺍﻟﺼﺤﻴﺢ ﻟﻐﺮﺽ ﺍﻟﺘﺴﻌﻴﺮ ﻭﻟﻀﻤﺎﻥ ﺣﺼﻮﻟﻚ ﻭﺃﻓﺮﺍﺩ ﺃﺳﺮﺗﻚ ﻋﻠﻰ ﺧﺪﻣﺎﺕ‬
family receive health care services as required according to your unfied policy benefit ‫ﺍﻟﺮﻋﺎﻳﺔ ﺍﻟﺼﺤﻴﺔ ﺑﺎﻟﺸﻜﻞ ﺍﻟﻤﻄﻠﻮﺏ ﺣﺴﺐ ﻣﻨﺎﻓﻊ ﺍﻟﻮﺛﻴﻘﺔ ﺍﻟﻤﻮﺣﺪﺓ‬

Addition ‫ﺇﺿﺎﻓﺔ‬ New ‫ﺟﺪﻳﺪ‬ Type ‫ﻧﻮﻉ ﺍﻟﻄﻠﺐ‬

CR No 7011507360 ‫ﺍﻟﺴﺠﻞ ﺍﻟﺘﺠﺎﺭﻱ‬ Entity Name HADDAJ AL HIJAZ EST ‫ﺃﺳﻢ ﺍﻟﻤﻨﺸﺄﺓ‬
Mobile No 0556860185 ‫ﺭﻗﻢ ﺍﻟﺠﻮﺍﻝ‬ Fuad Ahmed Mohammed Abdu ‫ﺍﺳﻢ ﺍﻟﻤﻮﻇﻒ‬
ID Number 2 2 0 3 0 6 5 8 2 2 ‫ﺭﻗﻢ ﺍﻟﻬﻮﻳﺔ‬
Male / ‫ﺫﻛﺮ‬ Yemen
Gender ‫ ﺍﻟﺠﻨﺲ‬Nationality ‫ ﺍﻟﺠﻨﺴﻴﺔ‬Marital status Married R ‫ﻣﺘﺰﻭﺝ‬ Single * ‫ﺃﻋﺰﺏ‬ ‫ﺍﻟﺤﺎﻟﺔ ﺍﻻﺟﺘﻤﺎﻋﻴﺔ‬
Please declare any of the below cases by marking P under the word Yes ‫ ﻓﻲ ﺍﻟﻤﺮﺑﻊ ﺗﺤﺖ ﻛﻠﻤﺔ ﻧﻌﻢ‬P ‫ﻳﺮﺟﻰ ﺍﻹﻓﺼﺎﺡ ﻋﻦ ﻭﺟﻮﺩ ﺃﻱ ﻣﻦ ﺍﻟﺤﺎﻻﺕ ﺍﺩﻧﺎﻩ ﺑﻮﺿﻊ ﺇﺷﺎﺭﺓ‬
"Below Undeclared Medical Case May Not Be Covered" No / ‫ﻻ‬ Yes / ‫ﻧﻌـﻢ‬ "‫"ﻟﻦ ﺗﺘﻢ ﺍﻟﺘﻐﻄﻴﺔ ﺍﻟﺘﺄﻣﻴﻨﻴﺔ ﻟﻠﺤﺎﻻﺕ ﺃﺩﻧﺎﻩ ﻓﻰ ﺣﺎﻝ ﻋﺪﻡ ﺍﻹﻓﺼﺎﺡ ﻋﻨﻬﺎ‬
Any hospital admission during last 12 months. ‫ ﺷﻬﺮ‬12 ‫ﻫﻞ ﺗﻢ ﺍﻟﺘﻨﻮﻳﻢ ﺑﺎﻟﻤﺴﺘﺸﻔﻰ ﺧﻼﻝ ﺃﺧﺮ‬
"Admission: registering as an admitted patient at the hospital until the following morning "
* * " ‫ ﺗﺴﺠﻴﻞ ﺍﻟﺸﺨﺺ ﺍﻟﻤﺆﻣﻦ ﻟﻪ ﻛﻤﺮﻳﺾ ﻣﻨﻮﻡ ﻓﻲ ﺍﻟﻤﺴﺘﺸﻔﻰ ﺣﺘﻰ ﺻﺒﺎﺡ ﺍﻟﻴﻮﻡ ﺍﻟﺘﺎﻟﻲ‬: ‫" ﺍﻟﺘﻨﻮﻳﻢ‬

Have you been diagnosed with any of the following chronic disease limited ‫ﻫﻞ ﺗﻢ ﺗﺸﺨﻴﺼﻚ ﺑﺄﻯ ﻣﻦ ﺍﻷﻣﺮﺍﺽ ﺍﻟﺘﺎﻟﻴﺔ ﻓﻘﻂ‬
to:Autism, listed Benign Tumor (Breast tumors, fibroid uterus, benign prostatic hyperplasia, ‫ﺃﻭﺭﺍﻡ ﺃﻭ‬,‫ﺗﻀﺨﻢ ﺍﻟﺒﺮﻭﺳﺘﺎﺗﺎ ﺍﻟﺤﻤﻴﺪ‬,‫ ﺃﻭﺭﺍﻡ ﺍﻟﺮﺣﻢ ﺍﻟﻠﻴﻔﻰ‬, ‫ﺍﻻﻭﺭﺍﻡ ﺍﻟﺤﻤﻴﺪﺓ ﺍﻟﺘﺎﻟﻴﺔ )ﺃﻭﺭﺍﻡ ﺍﻟﺜﺪﻯ‬,‫ﺍﻷﻭﺭﺍﻡ ﺍﻟﺴﺮﻃﺎﻧﻴﺔ‬,‫ﺍﻟﺘﻮﺣﺪ‬
thyroid goiter and parathyroid glands, live tumors, colon tumors). Malignant tumors, listed ‫ﺃﻣﺮﺍﺽ ﺍﻟﻘﻠﺐ ﺍﻟﺘﺎﻟﻴﺔ)ﺃﻣﺮﺍﺽ ﺷﺮﺍﻳﻴﻦ ﻭﺻﻤﺎﻣﺎﺕ ﺗﻀﺨﻢ ﺍﻟﻐﺪﺓ ﺍﻟﺪﺭﻗﻴﺔ‬, (‫ﺃﻭﺭﺍﻡ ﺍﻟﻘﻮﻟﻮﻥ‬, ‫ﻭﺃﻭﺭﺍﻡ ﺍﻻﻟﻜﺒﺪ‬,‫ﻭ ﺍﻟﺠﺎﺭ ﺍﻟﺪﺭﻗﻴﺔ‬
Cardiac diseases coronary and valve heart diseases, heart failure, cardiac fibrillation
myocardial infraction, heart clots). Chronic Hepatitis C. Gallstones Sever Kidney failure (stage
* * ‫ﺍﻻﻟﺘﻬﺎﺏ ﺍﻟﻜﺒﺪﻯ ﺍﻟﻔﻴﺮﻭﺳﻰ ﺍﻟﻤﺰﻣﻦ‬.( ‫ﺍﻟﺮﺟﻔﺎﻥ ﺍﻟﻘﻠﺒﻰ ﻭﺟﻠﻄﺎﺕ ﺍﻟﻘﻠﺐ‬, ‫ﻓﺸﻞ ﻋﻀﻠﺔ ﺍﻟﻘﻠﺐ‬, ‫ﺣﺼﻮﺍﺕ ﺍﻟﻤﺮﺍﺭﺓ ﺍﻟﻘﻠﺐ‬, ‫ﺝ ﻭﺳﻰ‬
,‫ ﺍﻟﺘﺮﺷﻴﺢ ﺍﻟﻜﻠﻮﻯ ﺃﻗﻞ ﻣﻦ‬,‫ ﺍﻟﻔﺸﻞ ﺍﻟﻜﻠﻮﻯﺍﻟﺸﺪﻳﺪ )ﺍﻟﻤﺮﺣﻠﺔ ﺍﻟﺨﺎﻣﺴﺔ ﻣﻦ ﺍﻣﺮﺍﺽ ﺍﻟﻜﻠﻰ ﺍﻟﺘﻰ ﺗﺴﺘﺪﻋﻰ ﺍﻟﻐﺴﻴﻞ ﺍﻟﻜﻠﻮﻯ‬15
5 Requiring dialysis, clearance of less tha 15 ml/ minute*). Urinary tract ‫ﻣﺮﺽ‬, ‫ﺩﻗﻴﻘﺔ(ﺣﺼﻮﺍﺕ ﺍﻟﻤﺴﺎﻟﻚ ﺍﻟﺒﻮﻟﻴﺔﺃﻣﺮﺍﺽ ﺍﻟﻤﻨﺎﻋﺔ ﺍﻟﺘﺎﻟﻴﺔ )ﺍﻟﺬﺋﺒﺔ ﺍﻟﺤﻤﺮﺍﺀﻭﺍﻟﺘﻬﺎﺏ ﺍﻟﻤﻔﺎﺻﻞ ﺍﻟﺮﻭﻣﺎﺗﻴﺰﻣﻴﺔﻭ ﺍﻟﺼﺪﻓﻴﺔ‬/‫ﻣﻞ‬
stones, hernias. Autoimmune disease (lupus, rheumatoid arthritis, psoriasis, Crohn's disease, ‫ﺍﻟﺘﻬﺎﺏ ﺍﻟﻘﻮﻟﻮﻥ ﺍﻟﺘﻘﺮﺣﻰ‬, ‫ﻛﺮﻭﻧﺰ‬,
ulcerative colitis,multiple sclerosis, celiac disease) ‫ﺣﺴﺎﺳﻴﺔ ﺍﻟﻘﻤﺢ‬, ‫ﺍﻟﺘﺼﻠﺐ ﺍﻟﻠﻮﻳﺤﻰ‬

Have you been diagnosed with any of the following congenital disorder or
hereditary diseases limited to: Cerebral palsy, Sickle cell disorder, Thalassemia, ‫ﻫﻞ ﺗﻢ ﺗﺸﺨﻴﺼﻚ ﺑﺄﻱ ﻣﻦ ﺍﻷﻣﺮﺍﺽ ﺍﻟﻮﺭﺍﺛﻴﺔ ﺃﻭ ﺍﻟﺘﺸﻮﻫﺎﺕ ﺍﻟﺨﻠﻘﻴﺔ ﺍﻟﺘﺎﻟﻴﺔ ﻓﻘﻂ‬
hemophilia, metabolic diseases, Hydrocephalus, spinal muscle atrophy, genital ‫ ﺿﻤﻮﺭ‬،‫ ﺃﺳﺘﺴﻘﺎﺀ ﺍﻟﺮﺃﺱ‬،‫ ﺃﻣﺮﺍﺽ ﺍﻟﺘﻤﺜﻴﻞ ﺍﻟﻐﺬﺍﺋﻲ‬،‫ ﺍﻟﻬﻴﻤﻮﻓﻴﻠﻴﺎ‬،‫ ﺍﻟﺘﻼﺳﻴﻤﻴﺎ‬،‫ﺍﺿﻄﺮﺍﺏ ﺍﻟﺨﻼﻳﺎ ﺍﻟﻤﻨﺠﻠﻴﺔ‬, ‫ﺍﻟﺸﻠﻞ ﺍﻟﺪﻣﺎﻏﻰ‬
malformations, chromosomal abnormalities. Gaucher's disease, G6PD Deficiency, cystic
fibrosis, hemochromatosis, Wilson disease. Polycystic Kidney Disease.
* * ‫ ﻣﺮﺽ ﺍﻟﺘﻜﺴﺮﺍﻟﻔﻮﻟﻰ‬،‫ ﻣﺮﺽ ﻏﻮﺷﺮ‬،‫ ﺃﻣﺮﺍﺽ ﺍﻟﻜﺮﻭﻣﻮﺳﻮﻣﺎﺕ‬،‫ ﺗﺸﻮﻫﺎﺕ ﺍﻷﻋﻀﺎﺀ ﺍﻟﺘﻨﺎﺳﻠﻴﺔ‬،‫ﺍﻟﻌﻀﻼﺕ ﺍﻟﺸﻮﻛﻲ‬
‫ﺗﻜﻴﺲ‬,‫ﻣﺮﺽ ﻭﻳﻠﺴﻮﻥ‬, (‫ ﻣﺮﺽ ﺗﻜﺪﺱ ﺍﻟﺤﺪﻳﺪ )ﻫﻴﻤﻮﻛﺮﻭﻣﺎﺗﻮﺳﻴﺲ‬،‫( ﺍﻟﺘﻠﻴﻒ ﺍﻟﻜﻴﺴﻲ ﻟﻠﺮﺋﺔ‬G6PD)
‫ﺍﻟﻜﻠﻴﺘﻴﻦ ﺍﻟﺨﻠﻔﻰ ﺍﻟﻮﺭﺍﺋﻰ‬

Have you been diagnosed with any of following eye diseases limited to: ،‫ ﻣﻴﺎﺓ ﺯﺭﻗﺎﺀ‬،‫ ﻣﻴﺎﺓ ﺑﻴﻀﺎﺀ‬:‫ﻫﻞ ﺗﻢ ﺗﺸﺨﻴﺼﻚ ﺑﺄﻱ ﻣﻦ ﺃﻣﺮﺍﺽ ﺍﻟﻌﻴﻦ ﺍﻟﺘﺎﻟﻴﺔ ﻓﻘﻂ‬
Cataract, Glaucoma, Retinal diseases. * * ‫ﺃﻣﺮﺍﺽ ﺍﻟﺸﺒﻜﻴﺔ‬
Have you been diagnosed with any of the following bone diseases limited ‫ ﺍﻹﻧﺰﻻﻕ ﺍﻟﻐﻀﺮﻭﻓﻲ‬:‫ﻫﻞ ﺗﻢ ﺗﺸﺨﻴﺼﻚ ﺑﺄﻱ ﻣﻦ ﺃﻣﺮﺍﺽ ﺍﻟﻌﻈﺎﻡ ﺍﻟﺘﺎﻟﻴﺔ ﻓﻘﻂ‬
to:Vertebral disc prolapse (moderate or severe), Scoliosis (moderate or severe)**, or ligament
tears, osteoarthritis (moderate or severe )
* * ‫ﺗﻤﺰﻕ ﺍﻷﺭﺑﻄﺔ‬،‫ﺍﻟﺘﻬﺎﺏ ﺍﻟﻤﻔﺎﺻﻞ‬،‫ﺇﻧﺤﺮﺍﻑ ﺍﻟﻌﻤﻮﺩ ﺍﻟﻔﻘﺮﻱ‬,‫ﺍﻟﺪﻳﺴﻚ‬

Pregnant Female Only ‫ﻟﻸﻧﺜﻰ ﺍﻟﺤﺎﻣﻞ ﻓﻘﻂ‬

‫ﺣﻤﻞ ﺣﺎﻟﻲ ﺟﻨﻴﻦ ﻭﺍﺣﺪ‬
Current Single Pregnancy
* *
‫ﺣﻤﻞ ﺣﺎﻟﻲ ﻣﻊ ﻗﻴﺼﺮﻳﺔ ﺳﺎﺑﻘﺔ‬
Current Single Pregnancy with Previous CS Delivery
* *
‫ﺣﻤﻞ ﺣﺎﻟﻲ ﻣﺘﻌﺪﺩ ﺍﻷﺟﻨﺔ‬
Current Multiple Pregnancy
* *
Expected delivery date .. / .. / .... ‫ﺗﺎﺭﻳﺦ ﺍﻟﻮﻻﺩﺓ ﺍﻟﻤﺘﻮﻗﻊ‬
Employee and dependents details that need to be added ‫ﺑﻴﺎﻧﺎﺕ ﺍﻟﻤﻮﻇﻒ ﻭﺃﻓﺮﺍﺩ ﺍﻟﻌﺎﺋﻠﺔ ﺍﻟﻤﺮﺍﺩ ﺇﺿﺎﻓﺘﻬﻢ‬
In case of a yes answer above, please declare the case in the table below ‫ ﺍﻟﺮﺟﺎﺀ ﺫﻛﺮ ﺍﻟﺤﺎﻟﺔ ﻓﻲ ﺍﻟﺠﺪﻭﻝ ﺃﺩﻧﺎﻩ‬،‫ﻓﻲ ﺣﺎﻟﺔ ﺍﻹﺟﺎﺑﺔ ﺑﻨﻌﻢ ﺃﻋﻼﻩ‬
‫ﺇﺳﻢ ﻣﻘﺪﻡ ﺍﻟﺨﺪﻣﺔ‬ ‫ﺍﻟﺤﺎﻟﺔ‬ ‫ﺭﻗﻢ ﺍﻟﺠﻮﺍﻝ‬ ‫ﺍﻟﻄﻮﻝ‬ ‫ﺍﻟﻮﺯﻥ‬ ‫ﺭﻗﻢ ﺍﻟﻬﻮﻳﺔ‬ ‫ﺍﻟﻘﺮﺍﺑﺔ‬ ‫ﺍﻟﺠﻨﺲ‬ ‫ ﺃﻓﺮﺍﺩ ﺍﻟﻌﺎﺋﻠﺔ‬/ ‫ﺍﺳﻢ ﺍﻟﻤﻮﻇﻒ‬ ‫ﻡ‬
2203065822 Employee Male / ‫ ﺫﻛﺮ‬Fuad Ahmed Mohammed Abdu 1
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Undertakings : ‫ﺍﻹﻗﺮﺍﺭ ﻭﺍﻟﺘﻔﻮﻳﺾ‬
1- I hereby undertake that all the above information is correct and the acceptance of my ‫ﻭﺍﻟﻤﻌﻠﻮﻣﺎﺕ ﺍﻟﻤﺬﻛﻮﺭﺓ ﺃﻋﻼﻩ ﻛﺎﻣﻠﺔ ﻭﺻﺤﻴﺤﺔ ﻭﺑﻨﺎﺀ ﻋﻠﻴﻪ ﻓﺈﻥ ﻗﺒﻮﻝ ﺍﻟﻄﻠﺐ ﺳﻴﺘﻢ‬: ‫ ﺃﻗﺮ ﺃﻥ ﺍﻟﺒﻴﺎﻧﺎﺕ‬-1
enrollment will be on the basis of such information and that Malath Cooperative Insurance ‫ﻋﻠﻰ ﺃﺳﺎﺱ ﻫﺬﻩ ﺍﻟﺒﻴﺎﻧﺎﺕ ﻭﺃﻥ ﺷﺮﻛﺔ ﻣﻼﺫ ﻟﻠﺘﺄﻣﻴﻦ ﺍﻟﺘﻌﺎﻭﻧﻲ ﻟﻬﺎ ﺍﻟﺤﻖ ﻓﻲ ﺍﻻﺗﺼﺎﻝ ﺑﺎﻟﻤﺴﺘﺸﻔﻴﺎﺕ ﺍﻟﺘﻲ‬
Company has the right to contact the hospital(s) I deal with to collect any ‫ﺃﺗﻌﺎﻣﻞ ﻣﻌﻬﺎ ﻟﺘﺰﻭﻳﺪﻫﺎ ﺑﺄﻱ ﻣﻌﻠﻮﻣﺎﺕ ﻃﺒﻴﺔ ﻗﺪ ﺗﺤﺘﺎﺝ ﺇﻟﻴﻬﺎ ﻟﺘﻘﻴﻴﻢ ﺍﻟﻤﺨﺎﻃﺮ‬
medical information needed to assess the risk(s).

2- I agree that Malath Cooperative Insurance Company has the right to reject the ‫ ﺃﻭﺍﻓﻖ ﻋﻠﻰ ﺃﺣﻘﻴﺔ ﺷﺮﻛﺔ ﻣﻼﺫ ﻟﻠﺘﺄﻣﻴﻦ ﻓﻲ ﺭﻓﺾ ﺍﻟﻤﻄﺎﻟﺒﺔ ﺃﻭ ﺍﻟﺘﻐﻄﻴﺔ ﻛﻠﻴﺎ ﻋﻨﺪ ﻋﺪﻡ ﺍﻹﻓﺼﺎﺡ ﻋﻦ ﻭﺟﻮﺩ ﺃﻱ ﻣﻦ ﺍﻟﺤﺎﻻﺕ‬-2
coverage/claims in full in case of no declaration of any cases prior to the contractual date or ‫ﺍﻟﻤﺬﻛﻮﺭﺓ ﺃﻋﻼﻩ ﺍﻟﺘﻲ ﻧﺸﺄﺕ ﻗﺒﻞ ﺗﺎﺭﻳﺦ ﺍﻟﺘﻌﺎﻗﺪ ﺃﻭ ﻗﺒﻞ ﺗﺴﺠﻴﻞ ﺃﻭ ﺇﺿﺎﻓﺔ ﻋﻀﻮ ﺧﻼﻝ ﻓﺘﺮﺓ ﺳﺮﻳﺎﻥ ﺍﻟﻌﻘﺪ‬
before enrolling or adding a new member during the contract.

3- I hereby confirm reading and understanding all points presented in this form and I agree that ‫ ﺃﻗﺮﺑﺄﻧﻲ ﻗﺪ ﻗﺮﺃﺕ ﻭﻓﻬﻤﺖ ﺟﻤﻴﻊ ﻣﺎ ﺟﺎﺀ ﻓﻲ ﻫﺬﺍ ﺍﻟﻨﻤﻮﺫﺝ ﻛﻤﺎ ﺃﺗﻌﻬﺪ ﺑﺄﻥ ﻋﺪﻡ ﺇﺷﺎﺭﺗﻲ ﺃﻣﺎﻡ ﺃﻱ ﻣﻦ‬-3
not marking any case is understood as “Nothing requires declaration” and I sign on these ‫ﺍﻟﺤﺎﻻﺕ ﺍﻟﻤﺬﻛﻮﺭﺓ ﺃﻋﻼﻩ ﻳﻌﺘﺒﺮ ﺑﻤﺜﺎﺑﺔ ﻧﻔﻲ ﻭﺟﻮﺩ ﻣﺎﻳﺴﺘﺤﻖ ﺍﻹﻓﺼﺎﺡ ﻋﻨﻪ ﻭﻋﻠﻴﻪ ﺃﻭﻗﻊ‬
basis.
4- Failure to fill the weight and height information will result in refusal to cover
the cost of obesity surgery. ‫ ﻋﺪﻡ ﺗﻌﺒﺌﺔ ﺑﻴﺎﻧﺎﺕ ﺍﻟﻄﻮﻝ ﻭﺍﻟﻮﺯﻥ ﺳﻴﺆﺩﻱ ﺇﻟﻰ ﺭﻓﺾ ﺗﻐﻄﻴﺔ ﺗﻜﺎﻟﻴﻒ ﻋﻤﻠﻴﺔ ﺟﺮﺍﺣﺔ ﺍﻟﺴﻤﻨﺔ ﺍﻟﻤﻔﺮﻃﺔ‬-4

Entity's stamp ‫ﺧﺘﻢ ﺟﻬﺔ ﺍﻟﻌﻤﻞ‬ Insured Signature ‫ﺗﻮﻗﻴﻊ ﺍﻟﻤﻮﻇﻒ‬ Date ‫ﺍﻟﺘﺎﺭﻳﺦ‬
.. / .. / ....

New_Health_Insurance.rdf Page 34 of 39 V.20 13-DEC-2023 01:30 PM

 ‫ﻧﻤﻮﺫﺝ ﺍﻻﻓﺼﺎﺡ ﺍﻟﻄﺒﻲ ﺍﻟﻤﻮﺣﺪ‬
Unified Medical Declaration Form
Product Code: A-MLTH-2-C-08-014
Dear Insured: ‫ﻋﺰﻳﺰﻱ ﺍﻟﻤﺆﻣﻦ ﻟﻪ‬
Please Fill out the form correctly for the purpose of pricing and to ensured that you and your ‫ﻧﺄﻣﻞ ﻗﻴﺎﻣﻚ ﺑﺘﻌﺒﺌﺔ ﻫﺬﺍ ﺍﻟﻨﻤﻮﺫﺝ ﺑﺎﻟﺸﻜﻞ ﺍﻟﺼﺤﻴﺢ ﻟﻐﺮﺽ ﺍﻟﺘﺴﻌﻴﺮ ﻭﻟﻀﻤﺎﻥ ﺣﺼﻮﻟﻚ ﻭﺃﻓﺮﺍﺩ ﺃﺳﺮﺗﻚ ﻋﻠﻰ ﺧﺪﻣﺎﺕ‬
family receive health care services as required according to your unfied policy benefit ‫ﺍﻟﺮﻋﺎﻳﺔ ﺍﻟﺼﺤﻴﺔ ﺑﺎﻟﺸﻜﻞ ﺍﻟﻤﻄﻠﻮﺏ ﺣﺴﺐ ﻣﻨﺎﻓﻊ ﺍﻟﻮﺛﻴﻘﺔ ﺍﻟﻤﻮﺣﺪﺓ‬

Addition ‫ﺇﺿﺎﻓﺔ‬ New ‫ﺟﺪﻳﺪ‬ Type ‫ﻧﻮﻉ ﺍﻟﻄﻠﺐ‬

CR No 7011507360 ‫ﺍﻟﺴﺠﻞ ﺍﻟﺘﺠﺎﺭﻱ‬ Entity Name HADDAJ AL HIJAZ EST ‫ﺃﺳﻢ ﺍﻟﻤﻨﺸﺄﺓ‬
Mobile No 0500850016 ‫ﺭﻗﻢ ﺍﻟﺠﻮﺍﻝ‬ Nur Mohammad Gias Uddin ‫ﺍﺳﻢ ﺍﻟﻤﻮﻇﻒ‬
ID Number 2 2 4 3 6 4 9 4 8 6 ‫ﺭﻗﻢ ﺍﻟﻬﻮﻳﺔ‬
Male / ‫ﺫﻛﺮ‬ Bangladesh
Gender ‫ ﺍﻟﺠﻨﺲ‬Nationality ‫ ﺍﻟﺠﻨﺴﻴﺔ‬Marital status Married * ‫ﻣﺘﺰﻭﺝ‬ Single R ‫ﺃﻋﺰﺏ‬ ‫ﺍﻟﺤﺎﻟﺔ ﺍﻻﺟﺘﻤﺎﻋﻴﺔ‬
Please declare any of the below cases by marking P under the word Yes ‫ ﻓﻲ ﺍﻟﻤﺮﺑﻊ ﺗﺤﺖ ﻛﻠﻤﺔ ﻧﻌﻢ‬P ‫ﻳﺮﺟﻰ ﺍﻹﻓﺼﺎﺡ ﻋﻦ ﻭﺟﻮﺩ ﺃﻱ ﻣﻦ ﺍﻟﺤﺎﻻﺕ ﺍﺩﻧﺎﻩ ﺑﻮﺿﻊ ﺇﺷﺎﺭﺓ‬
"Below Undeclared Medical Case May Not Be Covered" No / ‫ﻻ‬ Yes / ‫ﻧﻌـﻢ‬ "‫"ﻟﻦ ﺗﺘﻢ ﺍﻟﺘﻐﻄﻴﺔ ﺍﻟﺘﺄﻣﻴﻨﻴﺔ ﻟﻠﺤﺎﻻﺕ ﺃﺩﻧﺎﻩ ﻓﻰ ﺣﺎﻝ ﻋﺪﻡ ﺍﻹﻓﺼﺎﺡ ﻋﻨﻬﺎ‬
Any hospital admission during last 12 months. ‫ ﺷﻬﺮ‬12 ‫ﻫﻞ ﺗﻢ ﺍﻟﺘﻨﻮﻳﻢ ﺑﺎﻟﻤﺴﺘﺸﻔﻰ ﺧﻼﻝ ﺃﺧﺮ‬
"Admission: registering as an admitted patient at the hospital until the following morning "
* * " ‫ ﺗﺴﺠﻴﻞ ﺍﻟﺸﺨﺺ ﺍﻟﻤﺆﻣﻦ ﻟﻪ ﻛﻤﺮﻳﺾ ﻣﻨﻮﻡ ﻓﻲ ﺍﻟﻤﺴﺘﺸﻔﻰ ﺣﺘﻰ ﺻﺒﺎﺡ ﺍﻟﻴﻮﻡ ﺍﻟﺘﺎﻟﻲ‬: ‫" ﺍﻟﺘﻨﻮﻳﻢ‬

Have you been diagnosed with any of the following chronic disease limited ‫ﻫﻞ ﺗﻢ ﺗﺸﺨﻴﺼﻚ ﺑﺄﻯ ﻣﻦ ﺍﻷﻣﺮﺍﺽ ﺍﻟﺘﺎﻟﻴﺔ ﻓﻘﻂ‬
to:Autism, listed Benign Tumor (Breast tumors, fibroid uterus, benign prostatic hyperplasia, ‫ﺃﻭﺭﺍﻡ ﺃﻭ‬,‫ﺗﻀﺨﻢ ﺍﻟﺒﺮﻭﺳﺘﺎﺗﺎ ﺍﻟﺤﻤﻴﺪ‬,‫ ﺃﻭﺭﺍﻡ ﺍﻟﺮﺣﻢ ﺍﻟﻠﻴﻔﻰ‬, ‫ﺍﻻﻭﺭﺍﻡ ﺍﻟﺤﻤﻴﺪﺓ ﺍﻟﺘﺎﻟﻴﺔ )ﺃﻭﺭﺍﻡ ﺍﻟﺜﺪﻯ‬,‫ﺍﻷﻭﺭﺍﻡ ﺍﻟﺴﺮﻃﺎﻧﻴﺔ‬,‫ﺍﻟﺘﻮﺣﺪ‬
thyroid goiter and parathyroid glands, live tumors, colon tumors). Malignant tumors, listed ‫ﺃﻣﺮﺍﺽ ﺍﻟﻘﻠﺐ ﺍﻟﺘﺎﻟﻴﺔ)ﺃﻣﺮﺍﺽ ﺷﺮﺍﻳﻴﻦ ﻭﺻﻤﺎﻣﺎﺕ ﺗﻀﺨﻢ ﺍﻟﻐﺪﺓ ﺍﻟﺪﺭﻗﻴﺔ‬, (‫ﺃﻭﺭﺍﻡ ﺍﻟﻘﻮﻟﻮﻥ‬, ‫ﻭﺃﻭﺭﺍﻡ ﺍﻻﻟﻜﺒﺪ‬,‫ﻭ ﺍﻟﺠﺎﺭ ﺍﻟﺪﺭﻗﻴﺔ‬
Cardiac diseases coronary and valve heart diseases, heart failure, cardiac fibrillation
myocardial infraction, heart clots). Chronic Hepatitis C. Gallstones Sever Kidney failure (stage
* * ‫ﺍﻻﻟﺘﻬﺎﺏ ﺍﻟﻜﺒﺪﻯ ﺍﻟﻔﻴﺮﻭﺳﻰ ﺍﻟﻤﺰﻣﻦ‬.( ‫ﺍﻟﺮﺟﻔﺎﻥ ﺍﻟﻘﻠﺒﻰ ﻭﺟﻠﻄﺎﺕ ﺍﻟﻘﻠﺐ‬, ‫ﻓﺸﻞ ﻋﻀﻠﺔ ﺍﻟﻘﻠﺐ‬, ‫ﺣﺼﻮﺍﺕ ﺍﻟﻤﺮﺍﺭﺓ ﺍﻟﻘﻠﺐ‬, ‫ﺝ ﻭﺳﻰ‬
,‫ ﺍﻟﺘﺮﺷﻴﺢ ﺍﻟﻜﻠﻮﻯ ﺃﻗﻞ ﻣﻦ‬,‫ ﺍﻟﻔﺸﻞ ﺍﻟﻜﻠﻮﻯﺍﻟﺸﺪﻳﺪ )ﺍﻟﻤﺮﺣﻠﺔ ﺍﻟﺨﺎﻣﺴﺔ ﻣﻦ ﺍﻣﺮﺍﺽ ﺍﻟﻜﻠﻰ ﺍﻟﺘﻰ ﺗﺴﺘﺪﻋﻰ ﺍﻟﻐﺴﻴﻞ ﺍﻟﻜﻠﻮﻯ‬15
5 Requiring dialysis, clearance of less tha 15 ml/ minute*). Urinary tract ‫ﻣﺮﺽ‬, ‫ﺩﻗﻴﻘﺔ(ﺣﺼﻮﺍﺕ ﺍﻟﻤﺴﺎﻟﻚ ﺍﻟﺒﻮﻟﻴﺔﺃﻣﺮﺍﺽ ﺍﻟﻤﻨﺎﻋﺔ ﺍﻟﺘﺎﻟﻴﺔ )ﺍﻟﺬﺋﺒﺔ ﺍﻟﺤﻤﺮﺍﺀﻭﺍﻟﺘﻬﺎﺏ ﺍﻟﻤﻔﺎﺻﻞ ﺍﻟﺮﻭﻣﺎﺗﻴﺰﻣﻴﺔﻭ ﺍﻟﺼﺪﻓﻴﺔ‬/‫ﻣﻞ‬
stones, hernias. Autoimmune disease (lupus, rheumatoid arthritis, psoriasis, Crohn's disease, ‫ﺍﻟﺘﻬﺎﺏ ﺍﻟﻘﻮﻟﻮﻥ ﺍﻟﺘﻘﺮﺣﻰ‬, ‫ﻛﺮﻭﻧﺰ‬,
ulcerative colitis,multiple sclerosis, celiac disease) ‫ﺣﺴﺎﺳﻴﺔ ﺍﻟﻘﻤﺢ‬, ‫ﺍﻟﺘﺼﻠﺐ ﺍﻟﻠﻮﻳﺤﻰ‬

Have you been diagnosed with any of the following congenital disorder or
hereditary diseases limited to: Cerebral palsy, Sickle cell disorder, Thalassemia, ‫ﻫﻞ ﺗﻢ ﺗﺸﺨﻴﺼﻚ ﺑﺄﻱ ﻣﻦ ﺍﻷﻣﺮﺍﺽ ﺍﻟﻮﺭﺍﺛﻴﺔ ﺃﻭ ﺍﻟﺘﺸﻮﻫﺎﺕ ﺍﻟﺨﻠﻘﻴﺔ ﺍﻟﺘﺎﻟﻴﺔ ﻓﻘﻂ‬
hemophilia, metabolic diseases, Hydrocephalus, spinal muscle atrophy, genital ‫ ﺿﻤﻮﺭ‬،‫ ﺃﺳﺘﺴﻘﺎﺀ ﺍﻟﺮﺃﺱ‬،‫ ﺃﻣﺮﺍﺽ ﺍﻟﺘﻤﺜﻴﻞ ﺍﻟﻐﺬﺍﺋﻲ‬،‫ ﺍﻟﻬﻴﻤﻮﻓﻴﻠﻴﺎ‬،‫ ﺍﻟﺘﻼﺳﻴﻤﻴﺎ‬،‫ﺍﺿﻄﺮﺍﺏ ﺍﻟﺨﻼﻳﺎ ﺍﻟﻤﻨﺠﻠﻴﺔ‬, ‫ﺍﻟﺸﻠﻞ ﺍﻟﺪﻣﺎﻏﻰ‬
malformations, chromosomal abnormalities. Gaucher's disease, G6PD Deficiency, cystic
fibrosis, hemochromatosis, Wilson disease. Polycystic Kidney Disease.
* * ‫ ﻣﺮﺽ ﺍﻟﺘﻜﺴﺮﺍﻟﻔﻮﻟﻰ‬،‫ ﻣﺮﺽ ﻏﻮﺷﺮ‬،‫ ﺃﻣﺮﺍﺽ ﺍﻟﻜﺮﻭﻣﻮﺳﻮﻣﺎﺕ‬،‫ ﺗﺸﻮﻫﺎﺕ ﺍﻷﻋﻀﺎﺀ ﺍﻟﺘﻨﺎﺳﻠﻴﺔ‬،‫ﺍﻟﻌﻀﻼﺕ ﺍﻟﺸﻮﻛﻲ‬
‫ﺗﻜﻴﺲ‬,‫ﻣﺮﺽ ﻭﻳﻠﺴﻮﻥ‬, (‫ ﻣﺮﺽ ﺗﻜﺪﺱ ﺍﻟﺤﺪﻳﺪ )ﻫﻴﻤﻮﻛﺮﻭﻣﺎﺗﻮﺳﻴﺲ‬،‫( ﺍﻟﺘﻠﻴﻒ ﺍﻟﻜﻴﺴﻲ ﻟﻠﺮﺋﺔ‬G6PD)
‫ﺍﻟﻜﻠﻴﺘﻴﻦ ﺍﻟﺨﻠﻔﻰ ﺍﻟﻮﺭﺍﺋﻰ‬

Have you been diagnosed with any of following eye diseases limited to: ،‫ ﻣﻴﺎﺓ ﺯﺭﻗﺎﺀ‬،‫ ﻣﻴﺎﺓ ﺑﻴﻀﺎﺀ‬:‫ﻫﻞ ﺗﻢ ﺗﺸﺨﻴﺼﻚ ﺑﺄﻱ ﻣﻦ ﺃﻣﺮﺍﺽ ﺍﻟﻌﻴﻦ ﺍﻟﺘﺎﻟﻴﺔ ﻓﻘﻂ‬
Cataract, Glaucoma, Retinal diseases. * * ‫ﺃﻣﺮﺍﺽ ﺍﻟﺸﺒﻜﻴﺔ‬
Have you been diagnosed with any of the following bone diseases limited ‫ ﺍﻹﻧﺰﻻﻕ ﺍﻟﻐﻀﺮﻭﻓﻲ‬:‫ﻫﻞ ﺗﻢ ﺗﺸﺨﻴﺼﻚ ﺑﺄﻱ ﻣﻦ ﺃﻣﺮﺍﺽ ﺍﻟﻌﻈﺎﻡ ﺍﻟﺘﺎﻟﻴﺔ ﻓﻘﻂ‬
to:Vertebral disc prolapse (moderate or severe), Scoliosis (moderate or severe)**, or ligament
tears, osteoarthritis (moderate or severe )
* * ‫ﺗﻤﺰﻕ ﺍﻷﺭﺑﻄﺔ‬،‫ﺍﻟﺘﻬﺎﺏ ﺍﻟﻤﻔﺎﺻﻞ‬،‫ﺇﻧﺤﺮﺍﻑ ﺍﻟﻌﻤﻮﺩ ﺍﻟﻔﻘﺮﻱ‬,‫ﺍﻟﺪﻳﺴﻚ‬

Pregnant Female Only ‫ﻟﻸﻧﺜﻰ ﺍﻟﺤﺎﻣﻞ ﻓﻘﻂ‬

‫ﺣﻤﻞ ﺣﺎﻟﻲ ﺟﻨﻴﻦ ﻭﺍﺣﺪ‬
Current Single Pregnancy
* *
‫ﺣﻤﻞ ﺣﺎﻟﻲ ﻣﻊ ﻗﻴﺼﺮﻳﺔ ﺳﺎﺑﻘﺔ‬
Current Single Pregnancy with Previous CS Delivery
* *
‫ﺣﻤﻞ ﺣﺎﻟﻲ ﻣﺘﻌﺪﺩ ﺍﻷﺟﻨﺔ‬
Current Multiple Pregnancy
* *
Expected delivery date .. / .. / .... ‫ﺗﺎﺭﻳﺦ ﺍﻟﻮﻻﺩﺓ ﺍﻟﻤﺘﻮﻗﻊ‬
Employee and dependents details that need to be added ‫ﺑﻴﺎﻧﺎﺕ ﺍﻟﻤﻮﻇﻒ ﻭﺃﻓﺮﺍﺩ ﺍﻟﻌﺎﺋﻠﺔ ﺍﻟﻤﺮﺍﺩ ﺇﺿﺎﻓﺘﻬﻢ‬
In case of a yes answer above, please declare the case in the table below ‫ ﺍﻟﺮﺟﺎﺀ ﺫﻛﺮ ﺍﻟﺤﺎﻟﺔ ﻓﻲ ﺍﻟﺠﺪﻭﻝ ﺃﺩﻧﺎﻩ‬،‫ﻓﻲ ﺣﺎﻟﺔ ﺍﻹﺟﺎﺑﺔ ﺑﻨﻌﻢ ﺃﻋﻼﻩ‬
‫ﺇﺳﻢ ﻣﻘﺪﻡ ﺍﻟﺨﺪﻣﺔ‬ ‫ﺍﻟﺤﺎﻟﺔ‬ ‫ﺭﻗﻢ ﺍﻟﺠﻮﺍﻝ‬ ‫ﺍﻟﻄﻮﻝ‬ ‫ﺍﻟﻮﺯﻥ‬ ‫ﺭﻗﻢ ﺍﻟﻬﻮﻳﺔ‬ ‫ﺍﻟﻘﺮﺍﺑﺔ‬ ‫ﺍﻟﺠﻨﺲ‬ ‫ ﺃﻓﺮﺍﺩ ﺍﻟﻌﺎﺋﻠﺔ‬/ ‫ﺍﺳﻢ ﺍﻟﻤﻮﻇﻒ‬ ‫ﻡ‬
2243649486 Employee Male / ‫ ﺫﻛﺮ‬Nur Mohammad Gias Uddin 1
2
3
4
5
Undertakings : ‫ﺍﻹﻗﺮﺍﺭ ﻭﺍﻟﺘﻔﻮﻳﺾ‬
1- I hereby undertake that all the above information is correct and the acceptance of my ‫ﻭﺍﻟﻤﻌﻠﻮﻣﺎﺕ ﺍﻟﻤﺬﻛﻮﺭﺓ ﺃﻋﻼﻩ ﻛﺎﻣﻠﺔ ﻭﺻﺤﻴﺤﺔ ﻭﺑﻨﺎﺀ ﻋﻠﻴﻪ ﻓﺈﻥ ﻗﺒﻮﻝ ﺍﻟﻄﻠﺐ ﺳﻴﺘﻢ‬: ‫ ﺃﻗﺮ ﺃﻥ ﺍﻟﺒﻴﺎﻧﺎﺕ‬-1
enrollment will be on the basis of such information and that Malath Cooperative Insurance ‫ﻋﻠﻰ ﺃﺳﺎﺱ ﻫﺬﻩ ﺍﻟﺒﻴﺎﻧﺎﺕ ﻭﺃﻥ ﺷﺮﻛﺔ ﻣﻼﺫ ﻟﻠﺘﺄﻣﻴﻦ ﺍﻟﺘﻌﺎﻭﻧﻲ ﻟﻬﺎ ﺍﻟﺤﻖ ﻓﻲ ﺍﻻﺗﺼﺎﻝ ﺑﺎﻟﻤﺴﺘﺸﻔﻴﺎﺕ ﺍﻟﺘﻲ‬
Company has the right to contact the hospital(s) I deal with to collect any ‫ﺃﺗﻌﺎﻣﻞ ﻣﻌﻬﺎ ﻟﺘﺰﻭﻳﺪﻫﺎ ﺑﺄﻱ ﻣﻌﻠﻮﻣﺎﺕ ﻃﺒﻴﺔ ﻗﺪ ﺗﺤﺘﺎﺝ ﺇﻟﻴﻬﺎ ﻟﺘﻘﻴﻴﻢ ﺍﻟﻤﺨﺎﻃﺮ‬
medical information needed to assess the risk(s).

2- I agree that Malath Cooperative Insurance Company has the right to reject the ‫ ﺃﻭﺍﻓﻖ ﻋﻠﻰ ﺃﺣﻘﻴﺔ ﺷﺮﻛﺔ ﻣﻼﺫ ﻟﻠﺘﺄﻣﻴﻦ ﻓﻲ ﺭﻓﺾ ﺍﻟﻤﻄﺎﻟﺒﺔ ﺃﻭ ﺍﻟﺘﻐﻄﻴﺔ ﻛﻠﻴﺎ ﻋﻨﺪ ﻋﺪﻡ ﺍﻹﻓﺼﺎﺡ ﻋﻦ ﻭﺟﻮﺩ ﺃﻱ ﻣﻦ ﺍﻟﺤﺎﻻﺕ‬-2
coverage/claims in full in case of no declaration of any cases prior to the contractual date or ‫ﺍﻟﻤﺬﻛﻮﺭﺓ ﺃﻋﻼﻩ ﺍﻟﺘﻲ ﻧﺸﺄﺕ ﻗﺒﻞ ﺗﺎﺭﻳﺦ ﺍﻟﺘﻌﺎﻗﺪ ﺃﻭ ﻗﺒﻞ ﺗﺴﺠﻴﻞ ﺃﻭ ﺇﺿﺎﻓﺔ ﻋﻀﻮ ﺧﻼﻝ ﻓﺘﺮﺓ ﺳﺮﻳﺎﻥ ﺍﻟﻌﻘﺪ‬
before enrolling or adding a new member during the contract.

3- I hereby confirm reading and understanding all points presented in this form and I agree that ‫ ﺃﻗﺮﺑﺄﻧﻲ ﻗﺪ ﻗﺮﺃﺕ ﻭﻓﻬﻤﺖ ﺟﻤﻴﻊ ﻣﺎ ﺟﺎﺀ ﻓﻲ ﻫﺬﺍ ﺍﻟﻨﻤﻮﺫﺝ ﻛﻤﺎ ﺃﺗﻌﻬﺪ ﺑﺄﻥ ﻋﺪﻡ ﺇﺷﺎﺭﺗﻲ ﺃﻣﺎﻡ ﺃﻱ ﻣﻦ‬-3
not marking any case is understood as “Nothing requires declaration” and I sign on these ‫ﺍﻟﺤﺎﻻﺕ ﺍﻟﻤﺬﻛﻮﺭﺓ ﺃﻋﻼﻩ ﻳﻌﺘﺒﺮ ﺑﻤﺜﺎﺑﺔ ﻧﻔﻲ ﻭﺟﻮﺩ ﻣﺎﻳﺴﺘﺤﻖ ﺍﻹﻓﺼﺎﺡ ﻋﻨﻪ ﻭﻋﻠﻴﻪ ﺃﻭﻗﻊ‬
basis.
4- Failure to fill the weight and height information will result in refusal to cover
the cost of obesity surgery. ‫ ﻋﺪﻡ ﺗﻌﺒﺌﺔ ﺑﻴﺎﻧﺎﺕ ﺍﻟﻄﻮﻝ ﻭﺍﻟﻮﺯﻥ ﺳﻴﺆﺩﻱ ﺇﻟﻰ ﺭﻓﺾ ﺗﻐﻄﻴﺔ ﺗﻜﺎﻟﻴﻒ ﻋﻤﻠﻴﺔ ﺟﺮﺍﺣﺔ ﺍﻟﺴﻤﻨﺔ ﺍﻟﻤﻔﺮﻃﺔ‬-4

Entity's stamp ‫ﺧﺘﻢ ﺟﻬﺔ ﺍﻟﻌﻤﻞ‬ Insured Signature ‫ﺗﻮﻗﻴﻊ ﺍﻟﻤﻮﻇﻒ‬ Date ‫ﺍﻟﺘﺎﺭﻳﺦ‬
.. / .. / ....

New_Health_Insurance.rdf Page 35 of 39 V.20 13-DEC-2023 01:30 PM

 ‫ﻧﻤﻮﺫﺝ ﺍﻻﻓﺼﺎﺡ ﺍﻟﻄﺒﻲ ﺍﻟﻤﻮﺣﺪ‬
Unified Medical Declaration Form
Product Code: A-MLTH-2-C-08-014
Dear Insured: ‫ﻋﺰﻳﺰﻱ ﺍﻟﻤﺆﻣﻦ ﻟﻪ‬
Please Fill out the form correctly for the purpose of pricing and to ensured that you and your ‫ﻧﺄﻣﻞ ﻗﻴﺎﻣﻚ ﺑﺘﻌﺒﺌﺔ ﻫﺬﺍ ﺍﻟﻨﻤﻮﺫﺝ ﺑﺎﻟﺸﻜﻞ ﺍﻟﺼﺤﻴﺢ ﻟﻐﺮﺽ ﺍﻟﺘﺴﻌﻴﺮ ﻭﻟﻀﻤﺎﻥ ﺣﺼﻮﻟﻚ ﻭﺃﻓﺮﺍﺩ ﺃﺳﺮﺗﻚ ﻋﻠﻰ ﺧﺪﻣﺎﺕ‬
family receive health care services as required according to your unfied policy benefit ‫ﺍﻟﺮﻋﺎﻳﺔ ﺍﻟﺼﺤﻴﺔ ﺑﺎﻟﺸﻜﻞ ﺍﻟﻤﻄﻠﻮﺏ ﺣﺴﺐ ﻣﻨﺎﻓﻊ ﺍﻟﻮﺛﻴﻘﺔ ﺍﻟﻤﻮﺣﺪﺓ‬

Addition ‫ﺇﺿﺎﻓﺔ‬ New ‫ﺟﺪﻳﺪ‬ Type ‫ﻧﻮﻉ ﺍﻟﻄﻠﺐ‬

CR No 7011507360 ‫ﺍﻟﺴﺠﻞ ﺍﻟﺘﺠﺎﺭﻱ‬ Entity Name HADDAJ AL HIJAZ EST ‫ﺃﺳﻢ ﺍﻟﻤﻨﺸﺄﺓ‬
Mobile No 0543186882 ‫ﺭﻗﻢ ﺍﻟﺠﻮﺍﻝ‬ Abul Hasnat Shoms Uddin ‫ﺍﺳﻢ ﺍﻟﻤﻮﻇﻒ‬
ID Number 2 2 6 7 8 9 0 5 8 6 ‫ﺭﻗﻢ ﺍﻟﻬﻮﻳﺔ‬
Male / ‫ﺫﻛﺮ‬ Bangladesh
Gender ‫ ﺍﻟﺠﻨﺲ‬Nationality ‫ ﺍﻟﺠﻨﺴﻴﺔ‬Marital status Married R ‫ﻣﺘﺰﻭﺝ‬ Single * ‫ﺃﻋﺰﺏ‬ ‫ﺍﻟﺤﺎﻟﺔ ﺍﻻﺟﺘﻤﺎﻋﻴﺔ‬
Please declare any of the below cases by marking P under the word Yes ‫ ﻓﻲ ﺍﻟﻤﺮﺑﻊ ﺗﺤﺖ ﻛﻠﻤﺔ ﻧﻌﻢ‬P ‫ﻳﺮﺟﻰ ﺍﻹﻓﺼﺎﺡ ﻋﻦ ﻭﺟﻮﺩ ﺃﻱ ﻣﻦ ﺍﻟﺤﺎﻻﺕ ﺍﺩﻧﺎﻩ ﺑﻮﺿﻊ ﺇﺷﺎﺭﺓ‬
"Below Undeclared Medical Case May Not Be Covered" No / ‫ﻻ‬ Yes / ‫ﻧﻌـﻢ‬ "‫"ﻟﻦ ﺗﺘﻢ ﺍﻟﺘﻐﻄﻴﺔ ﺍﻟﺘﺄﻣﻴﻨﻴﺔ ﻟﻠﺤﺎﻻﺕ ﺃﺩﻧﺎﻩ ﻓﻰ ﺣﺎﻝ ﻋﺪﻡ ﺍﻹﻓﺼﺎﺡ ﻋﻨﻬﺎ‬
Any hospital admission during last 12 months. ‫ ﺷﻬﺮ‬12 ‫ﻫﻞ ﺗﻢ ﺍﻟﺘﻨﻮﻳﻢ ﺑﺎﻟﻤﺴﺘﺸﻔﻰ ﺧﻼﻝ ﺃﺧﺮ‬
"Admission: registering as an admitted patient at the hospital until the following morning "
* * " ‫ ﺗﺴﺠﻴﻞ ﺍﻟﺸﺨﺺ ﺍﻟﻤﺆﻣﻦ ﻟﻪ ﻛﻤﺮﻳﺾ ﻣﻨﻮﻡ ﻓﻲ ﺍﻟﻤﺴﺘﺸﻔﻰ ﺣﺘﻰ ﺻﺒﺎﺡ ﺍﻟﻴﻮﻡ ﺍﻟﺘﺎﻟﻲ‬: ‫" ﺍﻟﺘﻨﻮﻳﻢ‬

Have you been diagnosed with any of the following chronic disease limited ‫ﻫﻞ ﺗﻢ ﺗﺸﺨﻴﺼﻚ ﺑﺄﻯ ﻣﻦ ﺍﻷﻣﺮﺍﺽ ﺍﻟﺘﺎﻟﻴﺔ ﻓﻘﻂ‬
to:Autism, listed Benign Tumor (Breast tumors, fibroid uterus, benign prostatic hyperplasia, ‫ﺃﻭﺭﺍﻡ ﺃﻭ‬,‫ﺗﻀﺨﻢ ﺍﻟﺒﺮﻭﺳﺘﺎﺗﺎ ﺍﻟﺤﻤﻴﺪ‬,‫ ﺃﻭﺭﺍﻡ ﺍﻟﺮﺣﻢ ﺍﻟﻠﻴﻔﻰ‬, ‫ﺍﻻﻭﺭﺍﻡ ﺍﻟﺤﻤﻴﺪﺓ ﺍﻟﺘﺎﻟﻴﺔ )ﺃﻭﺭﺍﻡ ﺍﻟﺜﺪﻯ‬,‫ﺍﻷﻭﺭﺍﻡ ﺍﻟﺴﺮﻃﺎﻧﻴﺔ‬,‫ﺍﻟﺘﻮﺣﺪ‬
thyroid goiter and parathyroid glands, live tumors, colon tumors). Malignant tumors, listed ‫ﺃﻣﺮﺍﺽ ﺍﻟﻘﻠﺐ ﺍﻟﺘﺎﻟﻴﺔ)ﺃﻣﺮﺍﺽ ﺷﺮﺍﻳﻴﻦ ﻭﺻﻤﺎﻣﺎﺕ ﺗﻀﺨﻢ ﺍﻟﻐﺪﺓ ﺍﻟﺪﺭﻗﻴﺔ‬, (‫ﺃﻭﺭﺍﻡ ﺍﻟﻘﻮﻟﻮﻥ‬, ‫ﻭﺃﻭﺭﺍﻡ ﺍﻻﻟﻜﺒﺪ‬,‫ﻭ ﺍﻟﺠﺎﺭ ﺍﻟﺪﺭﻗﻴﺔ‬
Cardiac diseases coronary and valve heart diseases, heart failure, cardiac fibrillation
myocardial infraction, heart clots). Chronic Hepatitis C. Gallstones Sever Kidney failure (stage
* * ‫ﺍﻻﻟﺘﻬﺎﺏ ﺍﻟﻜﺒﺪﻯ ﺍﻟﻔﻴﺮﻭﺳﻰ ﺍﻟﻤﺰﻣﻦ‬.( ‫ﺍﻟﺮﺟﻔﺎﻥ ﺍﻟﻘﻠﺒﻰ ﻭﺟﻠﻄﺎﺕ ﺍﻟﻘﻠﺐ‬, ‫ﻓﺸﻞ ﻋﻀﻠﺔ ﺍﻟﻘﻠﺐ‬, ‫ﺣﺼﻮﺍﺕ ﺍﻟﻤﺮﺍﺭﺓ ﺍﻟﻘﻠﺐ‬, ‫ﺝ ﻭﺳﻰ‬
,‫ ﺍﻟﺘﺮﺷﻴﺢ ﺍﻟﻜﻠﻮﻯ ﺃﻗﻞ ﻣﻦ‬,‫ ﺍﻟﻔﺸﻞ ﺍﻟﻜﻠﻮﻯﺍﻟﺸﺪﻳﺪ )ﺍﻟﻤﺮﺣﻠﺔ ﺍﻟﺨﺎﻣﺴﺔ ﻣﻦ ﺍﻣﺮﺍﺽ ﺍﻟﻜﻠﻰ ﺍﻟﺘﻰ ﺗﺴﺘﺪﻋﻰ ﺍﻟﻐﺴﻴﻞ ﺍﻟﻜﻠﻮﻯ‬15
5 Requiring dialysis, clearance of less tha 15 ml/ minute*). Urinary tract ‫ﻣﺮﺽ‬, ‫ﺩﻗﻴﻘﺔ(ﺣﺼﻮﺍﺕ ﺍﻟﻤﺴﺎﻟﻚ ﺍﻟﺒﻮﻟﻴﺔﺃﻣﺮﺍﺽ ﺍﻟﻤﻨﺎﻋﺔ ﺍﻟﺘﺎﻟﻴﺔ )ﺍﻟﺬﺋﺒﺔ ﺍﻟﺤﻤﺮﺍﺀﻭﺍﻟﺘﻬﺎﺏ ﺍﻟﻤﻔﺎﺻﻞ ﺍﻟﺮﻭﻣﺎﺗﻴﺰﻣﻴﺔﻭ ﺍﻟﺼﺪﻓﻴﺔ‬/‫ﻣﻞ‬
stones, hernias. Autoimmune disease (lupus, rheumatoid arthritis, psoriasis, Crohn's disease, ‫ﺍﻟﺘﻬﺎﺏ ﺍﻟﻘﻮﻟﻮﻥ ﺍﻟﺘﻘﺮﺣﻰ‬, ‫ﻛﺮﻭﻧﺰ‬,
ulcerative colitis,multiple sclerosis, celiac disease) ‫ﺣﺴﺎﺳﻴﺔ ﺍﻟﻘﻤﺢ‬, ‫ﺍﻟﺘﺼﻠﺐ ﺍﻟﻠﻮﻳﺤﻰ‬

Have you been diagnosed with any of the following congenital disorder or
hereditary diseases limited to: Cerebral palsy, Sickle cell disorder, Thalassemia, ‫ﻫﻞ ﺗﻢ ﺗﺸﺨﻴﺼﻚ ﺑﺄﻱ ﻣﻦ ﺍﻷﻣﺮﺍﺽ ﺍﻟﻮﺭﺍﺛﻴﺔ ﺃﻭ ﺍﻟﺘﺸﻮﻫﺎﺕ ﺍﻟﺨﻠﻘﻴﺔ ﺍﻟﺘﺎﻟﻴﺔ ﻓﻘﻂ‬
hemophilia, metabolic diseases, Hydrocephalus, spinal muscle atrophy, genital ‫ ﺿﻤﻮﺭ‬،‫ ﺃﺳﺘﺴﻘﺎﺀ ﺍﻟﺮﺃﺱ‬،‫ ﺃﻣﺮﺍﺽ ﺍﻟﺘﻤﺜﻴﻞ ﺍﻟﻐﺬﺍﺋﻲ‬،‫ ﺍﻟﻬﻴﻤﻮﻓﻴﻠﻴﺎ‬،‫ ﺍﻟﺘﻼﺳﻴﻤﻴﺎ‬،‫ﺍﺿﻄﺮﺍﺏ ﺍﻟﺨﻼﻳﺎ ﺍﻟﻤﻨﺠﻠﻴﺔ‬, ‫ﺍﻟﺸﻠﻞ ﺍﻟﺪﻣﺎﻏﻰ‬
malformations, chromosomal abnormalities. Gaucher's disease, G6PD Deficiency, cystic
fibrosis, hemochromatosis, Wilson disease. Polycystic Kidney Disease.
* * ‫ ﻣﺮﺽ ﺍﻟﺘﻜﺴﺮﺍﻟﻔﻮﻟﻰ‬،‫ ﻣﺮﺽ ﻏﻮﺷﺮ‬،‫ ﺃﻣﺮﺍﺽ ﺍﻟﻜﺮﻭﻣﻮﺳﻮﻣﺎﺕ‬،‫ ﺗﺸﻮﻫﺎﺕ ﺍﻷﻋﻀﺎﺀ ﺍﻟﺘﻨﺎﺳﻠﻴﺔ‬،‫ﺍﻟﻌﻀﻼﺕ ﺍﻟﺸﻮﻛﻲ‬
‫ﺗﻜﻴﺲ‬,‫ﻣﺮﺽ ﻭﻳﻠﺴﻮﻥ‬, (‫ ﻣﺮﺽ ﺗﻜﺪﺱ ﺍﻟﺤﺪﻳﺪ )ﻫﻴﻤﻮﻛﺮﻭﻣﺎﺗﻮﺳﻴﺲ‬،‫( ﺍﻟﺘﻠﻴﻒ ﺍﻟﻜﻴﺴﻲ ﻟﻠﺮﺋﺔ‬G6PD)
‫ﺍﻟﻜﻠﻴﺘﻴﻦ ﺍﻟﺨﻠﻔﻰ ﺍﻟﻮﺭﺍﺋﻰ‬

Have you been diagnosed with any of following eye diseases limited to: ،‫ ﻣﻴﺎﺓ ﺯﺭﻗﺎﺀ‬،‫ ﻣﻴﺎﺓ ﺑﻴﻀﺎﺀ‬:‫ﻫﻞ ﺗﻢ ﺗﺸﺨﻴﺼﻚ ﺑﺄﻱ ﻣﻦ ﺃﻣﺮﺍﺽ ﺍﻟﻌﻴﻦ ﺍﻟﺘﺎﻟﻴﺔ ﻓﻘﻂ‬
Cataract, Glaucoma, Retinal diseases. * * ‫ﺃﻣﺮﺍﺽ ﺍﻟﺸﺒﻜﻴﺔ‬
Have you been diagnosed with any of the following bone diseases limited ‫ ﺍﻹﻧﺰﻻﻕ ﺍﻟﻐﻀﺮﻭﻓﻲ‬:‫ﻫﻞ ﺗﻢ ﺗﺸﺨﻴﺼﻚ ﺑﺄﻱ ﻣﻦ ﺃﻣﺮﺍﺽ ﺍﻟﻌﻈﺎﻡ ﺍﻟﺘﺎﻟﻴﺔ ﻓﻘﻂ‬
to:Vertebral disc prolapse (moderate or severe), Scoliosis (moderate or severe)**, or ligament
tears, osteoarthritis (moderate or severe )
* * ‫ﺗﻤﺰﻕ ﺍﻷﺭﺑﻄﺔ‬،‫ﺍﻟﺘﻬﺎﺏ ﺍﻟﻤﻔﺎﺻﻞ‬،‫ﺇﻧﺤﺮﺍﻑ ﺍﻟﻌﻤﻮﺩ ﺍﻟﻔﻘﺮﻱ‬,‫ﺍﻟﺪﻳﺴﻚ‬

Pregnant Female Only ‫ﻟﻸﻧﺜﻰ ﺍﻟﺤﺎﻣﻞ ﻓﻘﻂ‬

‫ﺣﻤﻞ ﺣﺎﻟﻲ ﺟﻨﻴﻦ ﻭﺍﺣﺪ‬
Current Single Pregnancy
* *
‫ﺣﻤﻞ ﺣﺎﻟﻲ ﻣﻊ ﻗﻴﺼﺮﻳﺔ ﺳﺎﺑﻘﺔ‬
Current Single Pregnancy with Previous CS Delivery
* *
‫ﺣﻤﻞ ﺣﺎﻟﻲ ﻣﺘﻌﺪﺩ ﺍﻷﺟﻨﺔ‬
Current Multiple Pregnancy
* *
Expected delivery date .. / .. / .... ‫ﺗﺎﺭﻳﺦ ﺍﻟﻮﻻﺩﺓ ﺍﻟﻤﺘﻮﻗﻊ‬
Employee and dependents details that need to be added ‫ﺑﻴﺎﻧﺎﺕ ﺍﻟﻤﻮﻇﻒ ﻭﺃﻓﺮﺍﺩ ﺍﻟﻌﺎﺋﻠﺔ ﺍﻟﻤﺮﺍﺩ ﺇﺿﺎﻓﺘﻬﻢ‬
In case of a yes answer above, please declare the case in the table below ‫ ﺍﻟﺮﺟﺎﺀ ﺫﻛﺮ ﺍﻟﺤﺎﻟﺔ ﻓﻲ ﺍﻟﺠﺪﻭﻝ ﺃﺩﻧﺎﻩ‬،‫ﻓﻲ ﺣﺎﻟﺔ ﺍﻹﺟﺎﺑﺔ ﺑﻨﻌﻢ ﺃﻋﻼﻩ‬
‫ﺇﺳﻢ ﻣﻘﺪﻡ ﺍﻟﺨﺪﻣﺔ‬ ‫ﺍﻟﺤﺎﻟﺔ‬ ‫ﺭﻗﻢ ﺍﻟﺠﻮﺍﻝ‬ ‫ﺍﻟﻄﻮﻝ‬ ‫ﺍﻟﻮﺯﻥ‬ ‫ﺭﻗﻢ ﺍﻟﻬﻮﻳﺔ‬ ‫ﺍﻟﻘﺮﺍﺑﺔ‬ ‫ﺍﻟﺠﻨﺲ‬ ‫ ﺃﻓﺮﺍﺩ ﺍﻟﻌﺎﺋﻠﺔ‬/ ‫ﺍﺳﻢ ﺍﻟﻤﻮﻇﻒ‬ ‫ﻡ‬
2267890586 Employee Male / ‫ ﺫﻛﺮ‬Abul Hasnat Shoms Uddin 1
2
3
4
5
Undertakings : ‫ﺍﻹﻗﺮﺍﺭ ﻭﺍﻟﺘﻔﻮﻳﺾ‬
1- I hereby undertake that all the above information is correct and the acceptance of my ‫ﻭﺍﻟﻤﻌﻠﻮﻣﺎﺕ ﺍﻟﻤﺬﻛﻮﺭﺓ ﺃﻋﻼﻩ ﻛﺎﻣﻠﺔ ﻭﺻﺤﻴﺤﺔ ﻭﺑﻨﺎﺀ ﻋﻠﻴﻪ ﻓﺈﻥ ﻗﺒﻮﻝ ﺍﻟﻄﻠﺐ ﺳﻴﺘﻢ‬: ‫ ﺃﻗﺮ ﺃﻥ ﺍﻟﺒﻴﺎﻧﺎﺕ‬-1
enrollment will be on the basis of such information and that Malath Cooperative Insurance ‫ﻋﻠﻰ ﺃﺳﺎﺱ ﻫﺬﻩ ﺍﻟﺒﻴﺎﻧﺎﺕ ﻭﺃﻥ ﺷﺮﻛﺔ ﻣﻼﺫ ﻟﻠﺘﺄﻣﻴﻦ ﺍﻟﺘﻌﺎﻭﻧﻲ ﻟﻬﺎ ﺍﻟﺤﻖ ﻓﻲ ﺍﻻﺗﺼﺎﻝ ﺑﺎﻟﻤﺴﺘﺸﻔﻴﺎﺕ ﺍﻟﺘﻲ‬
Company has the right to contact the hospital(s) I deal with to collect any ‫ﺃﺗﻌﺎﻣﻞ ﻣﻌﻬﺎ ﻟﺘﺰﻭﻳﺪﻫﺎ ﺑﺄﻱ ﻣﻌﻠﻮﻣﺎﺕ ﻃﺒﻴﺔ ﻗﺪ ﺗﺤﺘﺎﺝ ﺇﻟﻴﻬﺎ ﻟﺘﻘﻴﻴﻢ ﺍﻟﻤﺨﺎﻃﺮ‬
medical information needed to assess the risk(s).

2- I agree that Malath Cooperative Insurance Company has the right to reject the ‫ ﺃﻭﺍﻓﻖ ﻋﻠﻰ ﺃﺣﻘﻴﺔ ﺷﺮﻛﺔ ﻣﻼﺫ ﻟﻠﺘﺄﻣﻴﻦ ﻓﻲ ﺭﻓﺾ ﺍﻟﻤﻄﺎﻟﺒﺔ ﺃﻭ ﺍﻟﺘﻐﻄﻴﺔ ﻛﻠﻴﺎ ﻋﻨﺪ ﻋﺪﻡ ﺍﻹﻓﺼﺎﺡ ﻋﻦ ﻭﺟﻮﺩ ﺃﻱ ﻣﻦ ﺍﻟﺤﺎﻻﺕ‬-2
coverage/claims in full in case of no declaration of any cases prior to the contractual date or ‫ﺍﻟﻤﺬﻛﻮﺭﺓ ﺃﻋﻼﻩ ﺍﻟﺘﻲ ﻧﺸﺄﺕ ﻗﺒﻞ ﺗﺎﺭﻳﺦ ﺍﻟﺘﻌﺎﻗﺪ ﺃﻭ ﻗﺒﻞ ﺗﺴﺠﻴﻞ ﺃﻭ ﺇﺿﺎﻓﺔ ﻋﻀﻮ ﺧﻼﻝ ﻓﺘﺮﺓ ﺳﺮﻳﺎﻥ ﺍﻟﻌﻘﺪ‬
before enrolling or adding a new member during the contract.

3- I hereby confirm reading and understanding all points presented in this form and I agree that ‫ ﺃﻗﺮﺑﺄﻧﻲ ﻗﺪ ﻗﺮﺃﺕ ﻭﻓﻬﻤﺖ ﺟﻤﻴﻊ ﻣﺎ ﺟﺎﺀ ﻓﻲ ﻫﺬﺍ ﺍﻟﻨﻤﻮﺫﺝ ﻛﻤﺎ ﺃﺗﻌﻬﺪ ﺑﺄﻥ ﻋﺪﻡ ﺇﺷﺎﺭﺗﻲ ﺃﻣﺎﻡ ﺃﻱ ﻣﻦ‬-3
not marking any case is understood as “Nothing requires declaration” and I sign on these ‫ﺍﻟﺤﺎﻻﺕ ﺍﻟﻤﺬﻛﻮﺭﺓ ﺃﻋﻼﻩ ﻳﻌﺘﺒﺮ ﺑﻤﺜﺎﺑﺔ ﻧﻔﻲ ﻭﺟﻮﺩ ﻣﺎﻳﺴﺘﺤﻖ ﺍﻹﻓﺼﺎﺡ ﻋﻨﻪ ﻭﻋﻠﻴﻪ ﺃﻭﻗﻊ‬
basis.
4- Failure to fill the weight and height information will result in refusal to cover
the cost of obesity surgery. ‫ ﻋﺪﻡ ﺗﻌﺒﺌﺔ ﺑﻴﺎﻧﺎﺕ ﺍﻟﻄﻮﻝ ﻭﺍﻟﻮﺯﻥ ﺳﻴﺆﺩﻱ ﺇﻟﻰ ﺭﻓﺾ ﺗﻐﻄﻴﺔ ﺗﻜﺎﻟﻴﻒ ﻋﻤﻠﻴﺔ ﺟﺮﺍﺣﺔ ﺍﻟﺴﻤﻨﺔ ﺍﻟﻤﻔﺮﻃﺔ‬-4

Entity's stamp ‫ﺧﺘﻢ ﺟﻬﺔ ﺍﻟﻌﻤﻞ‬ Insured Signature ‫ﺗﻮﻗﻴﻊ ﺍﻟﻤﻮﻇﻒ‬ Date ‫ﺍﻟﺘﺎﺭﻳﺦ‬
.. / .. / ....

New_Health_Insurance.rdf Page 36 of 39 V.20 13-DEC-2023 01:30 PM

 ‫ﻧﻤﻮﺫﺝ ﺍﻻﻓﺼﺎﺡ ﺍﻟﻄﺒﻲ ﺍﻟﻤﻮﺣﺪ‬
Unified Medical Declaration Form
Product Code: A-MLTH-2-C-08-014
Dear Insured: ‫ﻋﺰﻳﺰﻱ ﺍﻟﻤﺆﻣﻦ ﻟﻪ‬
Please Fill out the form correctly for the purpose of pricing and to ensured that you and your ‫ﻧﺄﻣﻞ ﻗﻴﺎﻣﻚ ﺑﺘﻌﺒﺌﺔ ﻫﺬﺍ ﺍﻟﻨﻤﻮﺫﺝ ﺑﺎﻟﺸﻜﻞ ﺍﻟﺼﺤﻴﺢ ﻟﻐﺮﺽ ﺍﻟﺘﺴﻌﻴﺮ ﻭﻟﻀﻤﺎﻥ ﺣﺼﻮﻟﻚ ﻭﺃﻓﺮﺍﺩ ﺃﺳﺮﺗﻚ ﻋﻠﻰ ﺧﺪﻣﺎﺕ‬
family receive health care services as required according to your unfied policy benefit ‫ﺍﻟﺮﻋﺎﻳﺔ ﺍﻟﺼﺤﻴﺔ ﺑﺎﻟﺸﻜﻞ ﺍﻟﻤﻄﻠﻮﺏ ﺣﺴﺐ ﻣﻨﺎﻓﻊ ﺍﻟﻮﺛﻴﻘﺔ ﺍﻟﻤﻮﺣﺪﺓ‬

Addition ‫ﺇﺿﺎﻓﺔ‬ New ‫ﺟﺪﻳﺪ‬ Type ‫ﻧﻮﻉ ﺍﻟﻄﻠﺐ‬

CR No 7011507360 ‫ﺍﻟﺴﺠﻞ ﺍﻟﺘﺠﺎﺭﻱ‬ Entity Name HADDAJ AL HIJAZ EST ‫ﺃﺳﻢ ﺍﻟﻤﻨﺸﺄﺓ‬
Mobile No 0532678393 ‫ﺭﻗﻢ ﺍﻟﺠﻮﺍﻝ‬ Fahman Ahmed Mohammed Karama ‫ﺍﺳﻢ ﺍﻟﻤﻮﻇﻒ‬
ID Number 2 3 1 0 5 8 6 8 6 8 ‫ﺭﻗﻢ ﺍﻟﻬﻮﻳﺔ‬
Male / ‫ﺫﻛﺮ‬ Yemen
Gender ‫ ﺍﻟﺠﻨﺲ‬Nationality ‫ ﺍﻟﺠﻨﺴﻴﺔ‬Marital status Married * ‫ﻣﺘﺰﻭﺝ‬ Single R ‫ﺃﻋﺰﺏ‬ ‫ﺍﻟﺤﺎﻟﺔ ﺍﻻﺟﺘﻤﺎﻋﻴﺔ‬
Please declare any of the below cases by marking P under the word Yes ‫ ﻓﻲ ﺍﻟﻤﺮﺑﻊ ﺗﺤﺖ ﻛﻠﻤﺔ ﻧﻌﻢ‬P ‫ﻳﺮﺟﻰ ﺍﻹﻓﺼﺎﺡ ﻋﻦ ﻭﺟﻮﺩ ﺃﻱ ﻣﻦ ﺍﻟﺤﺎﻻﺕ ﺍﺩﻧﺎﻩ ﺑﻮﺿﻊ ﺇﺷﺎﺭﺓ‬
"Below Undeclared Medical Case May Not Be Covered" No / ‫ﻻ‬ Yes / ‫ﻧﻌـﻢ‬ "‫"ﻟﻦ ﺗﺘﻢ ﺍﻟﺘﻐﻄﻴﺔ ﺍﻟﺘﺄﻣﻴﻨﻴﺔ ﻟﻠﺤﺎﻻﺕ ﺃﺩﻧﺎﻩ ﻓﻰ ﺣﺎﻝ ﻋﺪﻡ ﺍﻹﻓﺼﺎﺡ ﻋﻨﻬﺎ‬
Any hospital admission during last 12 months. ‫ ﺷﻬﺮ‬12 ‫ﻫﻞ ﺗﻢ ﺍﻟﺘﻨﻮﻳﻢ ﺑﺎﻟﻤﺴﺘﺸﻔﻰ ﺧﻼﻝ ﺃﺧﺮ‬
"Admission: registering as an admitted patient at the hospital until the following morning "
* * " ‫ ﺗﺴﺠﻴﻞ ﺍﻟﺸﺨﺺ ﺍﻟﻤﺆﻣﻦ ﻟﻪ ﻛﻤﺮﻳﺾ ﻣﻨﻮﻡ ﻓﻲ ﺍﻟﻤﺴﺘﺸﻔﻰ ﺣﺘﻰ ﺻﺒﺎﺡ ﺍﻟﻴﻮﻡ ﺍﻟﺘﺎﻟﻲ‬: ‫" ﺍﻟﺘﻨﻮﻳﻢ‬

Have you been diagnosed with any of the following chronic disease limited ‫ﻫﻞ ﺗﻢ ﺗﺸﺨﻴﺼﻚ ﺑﺄﻯ ﻣﻦ ﺍﻷﻣﺮﺍﺽ ﺍﻟﺘﺎﻟﻴﺔ ﻓﻘﻂ‬
to:Autism, listed Benign Tumor (Breast tumors, fibroid uterus, benign prostatic hyperplasia, ‫ﺃﻭﺭﺍﻡ ﺃﻭ‬,‫ﺗﻀﺨﻢ ﺍﻟﺒﺮﻭﺳﺘﺎﺗﺎ ﺍﻟﺤﻤﻴﺪ‬,‫ ﺃﻭﺭﺍﻡ ﺍﻟﺮﺣﻢ ﺍﻟﻠﻴﻔﻰ‬, ‫ﺍﻻﻭﺭﺍﻡ ﺍﻟﺤﻤﻴﺪﺓ ﺍﻟﺘﺎﻟﻴﺔ )ﺃﻭﺭﺍﻡ ﺍﻟﺜﺪﻯ‬,‫ﺍﻷﻭﺭﺍﻡ ﺍﻟﺴﺮﻃﺎﻧﻴﺔ‬,‫ﺍﻟﺘﻮﺣﺪ‬
thyroid goiter and parathyroid glands, live tumors, colon tumors). Malignant tumors, listed ‫ﺃﻣﺮﺍﺽ ﺍﻟﻘﻠﺐ ﺍﻟﺘﺎﻟﻴﺔ)ﺃﻣﺮﺍﺽ ﺷﺮﺍﻳﻴﻦ ﻭﺻﻤﺎﻣﺎﺕ ﺗﻀﺨﻢ ﺍﻟﻐﺪﺓ ﺍﻟﺪﺭﻗﻴﺔ‬, (‫ﺃﻭﺭﺍﻡ ﺍﻟﻘﻮﻟﻮﻥ‬, ‫ﻭﺃﻭﺭﺍﻡ ﺍﻻﻟﻜﺒﺪ‬,‫ﻭ ﺍﻟﺠﺎﺭ ﺍﻟﺪﺭﻗﻴﺔ‬
Cardiac diseases coronary and valve heart diseases, heart failure, cardiac fibrillation
myocardial infraction, heart clots). Chronic Hepatitis C. Gallstones Sever Kidney failure (stage
* * ‫ﺍﻻﻟﺘﻬﺎﺏ ﺍﻟﻜﺒﺪﻯ ﺍﻟﻔﻴﺮﻭﺳﻰ ﺍﻟﻤﺰﻣﻦ‬.( ‫ﺍﻟﺮﺟﻔﺎﻥ ﺍﻟﻘﻠﺒﻰ ﻭﺟﻠﻄﺎﺕ ﺍﻟﻘﻠﺐ‬, ‫ﻓﺸﻞ ﻋﻀﻠﺔ ﺍﻟﻘﻠﺐ‬, ‫ﺣﺼﻮﺍﺕ ﺍﻟﻤﺮﺍﺭﺓ ﺍﻟﻘﻠﺐ‬, ‫ﺝ ﻭﺳﻰ‬
,‫ ﺍﻟﺘﺮﺷﻴﺢ ﺍﻟﻜﻠﻮﻯ ﺃﻗﻞ ﻣﻦ‬,‫ ﺍﻟﻔﺸﻞ ﺍﻟﻜﻠﻮﻯﺍﻟﺸﺪﻳﺪ )ﺍﻟﻤﺮﺣﻠﺔ ﺍﻟﺨﺎﻣﺴﺔ ﻣﻦ ﺍﻣﺮﺍﺽ ﺍﻟﻜﻠﻰ ﺍﻟﺘﻰ ﺗﺴﺘﺪﻋﻰ ﺍﻟﻐﺴﻴﻞ ﺍﻟﻜﻠﻮﻯ‬15
5 Requiring dialysis, clearance of less tha 15 ml/ minute*). Urinary tract ‫ﻣﺮﺽ‬, ‫ﺩﻗﻴﻘﺔ(ﺣﺼﻮﺍﺕ ﺍﻟﻤﺴﺎﻟﻚ ﺍﻟﺒﻮﻟﻴﺔﺃﻣﺮﺍﺽ ﺍﻟﻤﻨﺎﻋﺔ ﺍﻟﺘﺎﻟﻴﺔ )ﺍﻟﺬﺋﺒﺔ ﺍﻟﺤﻤﺮﺍﺀﻭﺍﻟﺘﻬﺎﺏ ﺍﻟﻤﻔﺎﺻﻞ ﺍﻟﺮﻭﻣﺎﺗﻴﺰﻣﻴﺔﻭ ﺍﻟﺼﺪﻓﻴﺔ‬/‫ﻣﻞ‬
stones, hernias. Autoimmune disease (lupus, rheumatoid arthritis, psoriasis, Crohn's disease, ‫ﺍﻟﺘﻬﺎﺏ ﺍﻟﻘﻮﻟﻮﻥ ﺍﻟﺘﻘﺮﺣﻰ‬, ‫ﻛﺮﻭﻧﺰ‬,
ulcerative colitis,multiple sclerosis, celiac disease) ‫ﺣﺴﺎﺳﻴﺔ ﺍﻟﻘﻤﺢ‬, ‫ﺍﻟﺘﺼﻠﺐ ﺍﻟﻠﻮﻳﺤﻰ‬

Have you been diagnosed with any of the following congenital disorder or
hereditary diseases limited to: Cerebral palsy, Sickle cell disorder, Thalassemia, ‫ﻫﻞ ﺗﻢ ﺗﺸﺨﻴﺼﻚ ﺑﺄﻱ ﻣﻦ ﺍﻷﻣﺮﺍﺽ ﺍﻟﻮﺭﺍﺛﻴﺔ ﺃﻭ ﺍﻟﺘﺸﻮﻫﺎﺕ ﺍﻟﺨﻠﻘﻴﺔ ﺍﻟﺘﺎﻟﻴﺔ ﻓﻘﻂ‬
hemophilia, metabolic diseases, Hydrocephalus, spinal muscle atrophy, genital ‫ ﺿﻤﻮﺭ‬،‫ ﺃﺳﺘﺴﻘﺎﺀ ﺍﻟﺮﺃﺱ‬،‫ ﺃﻣﺮﺍﺽ ﺍﻟﺘﻤﺜﻴﻞ ﺍﻟﻐﺬﺍﺋﻲ‬،‫ ﺍﻟﻬﻴﻤﻮﻓﻴﻠﻴﺎ‬،‫ ﺍﻟﺘﻼﺳﻴﻤﻴﺎ‬،‫ﺍﺿﻄﺮﺍﺏ ﺍﻟﺨﻼﻳﺎ ﺍﻟﻤﻨﺠﻠﻴﺔ‬, ‫ﺍﻟﺸﻠﻞ ﺍﻟﺪﻣﺎﻏﻰ‬
malformations, chromosomal abnormalities. Gaucher's disease, G6PD Deficiency, cystic
fibrosis, hemochromatosis, Wilson disease. Polycystic Kidney Disease.
* * ‫ ﻣﺮﺽ ﺍﻟﺘﻜﺴﺮﺍﻟﻔﻮﻟﻰ‬،‫ ﻣﺮﺽ ﻏﻮﺷﺮ‬،‫ ﺃﻣﺮﺍﺽ ﺍﻟﻜﺮﻭﻣﻮﺳﻮﻣﺎﺕ‬،‫ ﺗﺸﻮﻫﺎﺕ ﺍﻷﻋﻀﺎﺀ ﺍﻟﺘﻨﺎﺳﻠﻴﺔ‬،‫ﺍﻟﻌﻀﻼﺕ ﺍﻟﺸﻮﻛﻲ‬
‫ﺗﻜﻴﺲ‬,‫ﻣﺮﺽ ﻭﻳﻠﺴﻮﻥ‬, (‫ ﻣﺮﺽ ﺗﻜﺪﺱ ﺍﻟﺤﺪﻳﺪ )ﻫﻴﻤﻮﻛﺮﻭﻣﺎﺗﻮﺳﻴﺲ‬،‫( ﺍﻟﺘﻠﻴﻒ ﺍﻟﻜﻴﺴﻲ ﻟﻠﺮﺋﺔ‬G6PD)
‫ﺍﻟﻜﻠﻴﺘﻴﻦ ﺍﻟﺨﻠﻔﻰ ﺍﻟﻮﺭﺍﺋﻰ‬

Have you been diagnosed with any of following eye diseases limited to: ،‫ ﻣﻴﺎﺓ ﺯﺭﻗﺎﺀ‬،‫ ﻣﻴﺎﺓ ﺑﻴﻀﺎﺀ‬:‫ﻫﻞ ﺗﻢ ﺗﺸﺨﻴﺼﻚ ﺑﺄﻱ ﻣﻦ ﺃﻣﺮﺍﺽ ﺍﻟﻌﻴﻦ ﺍﻟﺘﺎﻟﻴﺔ ﻓﻘﻂ‬
Cataract, Glaucoma, Retinal diseases. * * ‫ﺃﻣﺮﺍﺽ ﺍﻟﺸﺒﻜﻴﺔ‬
Have you been diagnosed with any of the following bone diseases limited ‫ ﺍﻹﻧﺰﻻﻕ ﺍﻟﻐﻀﺮﻭﻓﻲ‬:‫ﻫﻞ ﺗﻢ ﺗﺸﺨﻴﺼﻚ ﺑﺄﻱ ﻣﻦ ﺃﻣﺮﺍﺽ ﺍﻟﻌﻈﺎﻡ ﺍﻟﺘﺎﻟﻴﺔ ﻓﻘﻂ‬
to:Vertebral disc prolapse (moderate or severe), Scoliosis (moderate or severe)**, or ligament
tears, osteoarthritis (moderate or severe )
* * ‫ﺗﻤﺰﻕ ﺍﻷﺭﺑﻄﺔ‬،‫ﺍﻟﺘﻬﺎﺏ ﺍﻟﻤﻔﺎﺻﻞ‬،‫ﺇﻧﺤﺮﺍﻑ ﺍﻟﻌﻤﻮﺩ ﺍﻟﻔﻘﺮﻱ‬,‫ﺍﻟﺪﻳﺴﻚ‬

Pregnant Female Only ‫ﻟﻸﻧﺜﻰ ﺍﻟﺤﺎﻣﻞ ﻓﻘﻂ‬

‫ﺣﻤﻞ ﺣﺎﻟﻲ ﺟﻨﻴﻦ ﻭﺍﺣﺪ‬
Current Single Pregnancy
* *
‫ﺣﻤﻞ ﺣﺎﻟﻲ ﻣﻊ ﻗﻴﺼﺮﻳﺔ ﺳﺎﺑﻘﺔ‬
Current Single Pregnancy with Previous CS Delivery
* *
‫ﺣﻤﻞ ﺣﺎﻟﻲ ﻣﺘﻌﺪﺩ ﺍﻷﺟﻨﺔ‬
Current Multiple Pregnancy
* *
Expected delivery date .. / .. / .... ‫ﺗﺎﺭﻳﺦ ﺍﻟﻮﻻﺩﺓ ﺍﻟﻤﺘﻮﻗﻊ‬
Employee and dependents details that need to be added ‫ﺑﻴﺎﻧﺎﺕ ﺍﻟﻤﻮﻇﻒ ﻭﺃﻓﺮﺍﺩ ﺍﻟﻌﺎﺋﻠﺔ ﺍﻟﻤﺮﺍﺩ ﺇﺿﺎﻓﺘﻬﻢ‬
In case of a yes answer above, please declare the case in the table below ‫ ﺍﻟﺮﺟﺎﺀ ﺫﻛﺮ ﺍﻟﺤﺎﻟﺔ ﻓﻲ ﺍﻟﺠﺪﻭﻝ ﺃﺩﻧﺎﻩ‬،‫ﻓﻲ ﺣﺎﻟﺔ ﺍﻹﺟﺎﺑﺔ ﺑﻨﻌﻢ ﺃﻋﻼﻩ‬
‫ﺇﺳﻢ ﻣﻘﺪﻡ ﺍﻟﺨﺪﻣﺔ‬ ‫ﺍﻟﺤﺎﻟﺔ‬ ‫ﺭﻗﻢ ﺍﻟﺠﻮﺍﻝ‬ ‫ﺍﻟﻄﻮﻝ‬ ‫ﺍﻟﻮﺯﻥ‬ ‫ﺭﻗﻢ ﺍﻟﻬﻮﻳﺔ‬ ‫ﺍﻟﻘﺮﺍﺑﺔ‬ ‫ﺍﻟﺠﻨﺲ‬ ‫ ﺃﻓﺮﺍﺩ ﺍﻟﻌﺎﺋﻠﺔ‬/ ‫ﺍﺳﻢ ﺍﻟﻤﻮﻇﻒ‬ ‫ﻡ‬
2310586868 Employee Male / ‫ ﺫﻛﺮ‬Fahman Ahmed Mohammed K 1
2
3
4
5
Undertakings : ‫ﺍﻹﻗﺮﺍﺭ ﻭﺍﻟﺘﻔﻮﻳﺾ‬
1- I hereby undertake that all the above information is correct and the acceptance of my ‫ﻭﺍﻟﻤﻌﻠﻮﻣﺎﺕ ﺍﻟﻤﺬﻛﻮﺭﺓ ﺃﻋﻼﻩ ﻛﺎﻣﻠﺔ ﻭﺻﺤﻴﺤﺔ ﻭﺑﻨﺎﺀ ﻋﻠﻴﻪ ﻓﺈﻥ ﻗﺒﻮﻝ ﺍﻟﻄﻠﺐ ﺳﻴﺘﻢ‬: ‫ ﺃﻗﺮ ﺃﻥ ﺍﻟﺒﻴﺎﻧﺎﺕ‬-1
enrollment will be on the basis of such information and that Malath Cooperative Insurance ‫ﻋﻠﻰ ﺃﺳﺎﺱ ﻫﺬﻩ ﺍﻟﺒﻴﺎﻧﺎﺕ ﻭﺃﻥ ﺷﺮﻛﺔ ﻣﻼﺫ ﻟﻠﺘﺄﻣﻴﻦ ﺍﻟﺘﻌﺎﻭﻧﻲ ﻟﻬﺎ ﺍﻟﺤﻖ ﻓﻲ ﺍﻻﺗﺼﺎﻝ ﺑﺎﻟﻤﺴﺘﺸﻔﻴﺎﺕ ﺍﻟﺘﻲ‬
Company has the right to contact the hospital(s) I deal with to collect any ‫ﺃﺗﻌﺎﻣﻞ ﻣﻌﻬﺎ ﻟﺘﺰﻭﻳﺪﻫﺎ ﺑﺄﻱ ﻣﻌﻠﻮﻣﺎﺕ ﻃﺒﻴﺔ ﻗﺪ ﺗﺤﺘﺎﺝ ﺇﻟﻴﻬﺎ ﻟﺘﻘﻴﻴﻢ ﺍﻟﻤﺨﺎﻃﺮ‬
medical information needed to assess the risk(s).

2- I agree that Malath Cooperative Insurance Company has the right to reject the ‫ ﺃﻭﺍﻓﻖ ﻋﻠﻰ ﺃﺣﻘﻴﺔ ﺷﺮﻛﺔ ﻣﻼﺫ ﻟﻠﺘﺄﻣﻴﻦ ﻓﻲ ﺭﻓﺾ ﺍﻟﻤﻄﺎﻟﺒﺔ ﺃﻭ ﺍﻟﺘﻐﻄﻴﺔ ﻛﻠﻴﺎ ﻋﻨﺪ ﻋﺪﻡ ﺍﻹﻓﺼﺎﺡ ﻋﻦ ﻭﺟﻮﺩ ﺃﻱ ﻣﻦ ﺍﻟﺤﺎﻻﺕ‬-2
coverage/claims in full in case of no declaration of any cases prior to the contractual date or ‫ﺍﻟﻤﺬﻛﻮﺭﺓ ﺃﻋﻼﻩ ﺍﻟﺘﻲ ﻧﺸﺄﺕ ﻗﺒﻞ ﺗﺎﺭﻳﺦ ﺍﻟﺘﻌﺎﻗﺪ ﺃﻭ ﻗﺒﻞ ﺗﺴﺠﻴﻞ ﺃﻭ ﺇﺿﺎﻓﺔ ﻋﻀﻮ ﺧﻼﻝ ﻓﺘﺮﺓ ﺳﺮﻳﺎﻥ ﺍﻟﻌﻘﺪ‬
before enrolling or adding a new member during the contract.

3- I hereby confirm reading and understanding all points presented in this form and I agree that ‫ ﺃﻗﺮﺑﺄﻧﻲ ﻗﺪ ﻗﺮﺃﺕ ﻭﻓﻬﻤﺖ ﺟﻤﻴﻊ ﻣﺎ ﺟﺎﺀ ﻓﻲ ﻫﺬﺍ ﺍﻟﻨﻤﻮﺫﺝ ﻛﻤﺎ ﺃﺗﻌﻬﺪ ﺑﺄﻥ ﻋﺪﻡ ﺇﺷﺎﺭﺗﻲ ﺃﻣﺎﻡ ﺃﻱ ﻣﻦ‬-3
not marking any case is understood as “Nothing requires declaration” and I sign on these ‫ﺍﻟﺤﺎﻻﺕ ﺍﻟﻤﺬﻛﻮﺭﺓ ﺃﻋﻼﻩ ﻳﻌﺘﺒﺮ ﺑﻤﺜﺎﺑﺔ ﻧﻔﻲ ﻭﺟﻮﺩ ﻣﺎﻳﺴﺘﺤﻖ ﺍﻹﻓﺼﺎﺡ ﻋﻨﻪ ﻭﻋﻠﻴﻪ ﺃﻭﻗﻊ‬
basis.
4- Failure to fill the weight and height information will result in refusal to cover
the cost of obesity surgery. ‫ ﻋﺪﻡ ﺗﻌﺒﺌﺔ ﺑﻴﺎﻧﺎﺕ ﺍﻟﻄﻮﻝ ﻭﺍﻟﻮﺯﻥ ﺳﻴﺆﺩﻱ ﺇﻟﻰ ﺭﻓﺾ ﺗﻐﻄﻴﺔ ﺗﻜﺎﻟﻴﻒ ﻋﻤﻠﻴﺔ ﺟﺮﺍﺣﺔ ﺍﻟﺴﻤﻨﺔ ﺍﻟﻤﻔﺮﻃﺔ‬-4

Entity's stamp ‫ﺧﺘﻢ ﺟﻬﺔ ﺍﻟﻌﻤﻞ‬ Insured Signature ‫ﺗﻮﻗﻴﻊ ﺍﻟﻤﻮﻇﻒ‬ Date ‫ﺍﻟﺘﺎﺭﻳﺦ‬
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New_Health_Insurance.rdf Page 37 of 39 V.20 13-DEC-2023 01:30 PM

 ‫ﻧﻤﻮﺫﺝ ﺍﻻﻓﺼﺎﺡ ﺍﻟﻄﺒﻲ ﺍﻟﻤﻮﺣﺪ‬
Unified Medical Declaration Form
Product Code: A-MLTH-2-C-08-014
Dear Insured: ‫ﻋﺰﻳﺰﻱ ﺍﻟﻤﺆﻣﻦ ﻟﻪ‬
Please Fill out the form correctly for the purpose of pricing and to ensured that you and your ‫ﻧﺄﻣﻞ ﻗﻴﺎﻣﻚ ﺑﺘﻌﺒﺌﺔ ﻫﺬﺍ ﺍﻟﻨﻤﻮﺫﺝ ﺑﺎﻟﺸﻜﻞ ﺍﻟﺼﺤﻴﺢ ﻟﻐﺮﺽ ﺍﻟﺘﺴﻌﻴﺮ ﻭﻟﻀﻤﺎﻥ ﺣﺼﻮﻟﻚ ﻭﺃﻓﺮﺍﺩ ﺃﺳﺮﺗﻚ ﻋﻠﻰ ﺧﺪﻣﺎﺕ‬
family receive health care services as required according to your unfied policy benefit ‫ﺍﻟﺮﻋﺎﻳﺔ ﺍﻟﺼﺤﻴﺔ ﺑﺎﻟﺸﻜﻞ ﺍﻟﻤﻄﻠﻮﺏ ﺣﺴﺐ ﻣﻨﺎﻓﻊ ﺍﻟﻮﺛﻴﻘﺔ ﺍﻟﻤﻮﺣﺪﺓ‬

Addition ‫ﺇﺿﺎﻓﺔ‬ New ‫ﺟﺪﻳﺪ‬ Type ‫ﻧﻮﻉ ﺍﻟﻄﻠﺐ‬

CR No 7011507360 ‫ﺍﻟﺴﺠﻞ ﺍﻟﺘﺠﺎﺭﻱ‬ Entity Name HADDAJ AL HIJAZ EST ‫ﺃﺳﻢ ﺍﻟﻤﻨﺸﺄﺓ‬
Mobile No 0501176016 ‫ﺭﻗﻢ ﺍﻟﺠﻮﺍﻝ‬ Muhammad Saleh Abdul Ghafoor ‫ﺍﺳﻢ ﺍﻟﻤﻮﻇﻒ‬
ID Number 2 3 2 6 6 5 5 4 9 1 ‫ﺭﻗﻢ ﺍﻟﻬﻮﻳﺔ‬
Male / ‫ﺫﻛﺮ‬ Pakistan
Gender ‫ ﺍﻟﺠﻨﺲ‬Nationality ‫ ﺍﻟﺠﻨﺴﻴﺔ‬Marital status Married R ‫ﻣﺘﺰﻭﺝ‬ Single * ‫ﺃﻋﺰﺏ‬ ‫ﺍﻟﺤﺎﻟﺔ ﺍﻻﺟﺘﻤﺎﻋﻴﺔ‬
Please declare any of the below cases by marking P under the word Yes ‫ ﻓﻲ ﺍﻟﻤﺮﺑﻊ ﺗﺤﺖ ﻛﻠﻤﺔ ﻧﻌﻢ‬P ‫ﻳﺮﺟﻰ ﺍﻹﻓﺼﺎﺡ ﻋﻦ ﻭﺟﻮﺩ ﺃﻱ ﻣﻦ ﺍﻟﺤﺎﻻﺕ ﺍﺩﻧﺎﻩ ﺑﻮﺿﻊ ﺇﺷﺎﺭﺓ‬
"Below Undeclared Medical Case May Not Be Covered" No / ‫ﻻ‬ Yes / ‫ﻧﻌـﻢ‬ "‫"ﻟﻦ ﺗﺘﻢ ﺍﻟﺘﻐﻄﻴﺔ ﺍﻟﺘﺄﻣﻴﻨﻴﺔ ﻟﻠﺤﺎﻻﺕ ﺃﺩﻧﺎﻩ ﻓﻰ ﺣﺎﻝ ﻋﺪﻡ ﺍﻹﻓﺼﺎﺡ ﻋﻨﻬﺎ‬
Any hospital admission during last 12 months. ‫ ﺷﻬﺮ‬12 ‫ﻫﻞ ﺗﻢ ﺍﻟﺘﻨﻮﻳﻢ ﺑﺎﻟﻤﺴﺘﺸﻔﻰ ﺧﻼﻝ ﺃﺧﺮ‬
"Admission: registering as an admitted patient at the hospital until the following morning "
* * " ‫ ﺗﺴﺠﻴﻞ ﺍﻟﺸﺨﺺ ﺍﻟﻤﺆﻣﻦ ﻟﻪ ﻛﻤﺮﻳﺾ ﻣﻨﻮﻡ ﻓﻲ ﺍﻟﻤﺴﺘﺸﻔﻰ ﺣﺘﻰ ﺻﺒﺎﺡ ﺍﻟﻴﻮﻡ ﺍﻟﺘﺎﻟﻲ‬: ‫" ﺍﻟﺘﻨﻮﻳﻢ‬

Have you been diagnosed with any of the following chronic disease limited ‫ﻫﻞ ﺗﻢ ﺗﺸﺨﻴﺼﻚ ﺑﺄﻯ ﻣﻦ ﺍﻷﻣﺮﺍﺽ ﺍﻟﺘﺎﻟﻴﺔ ﻓﻘﻂ‬
to:Autism, listed Benign Tumor (Breast tumors, fibroid uterus, benign prostatic hyperplasia, ‫ﺃﻭﺭﺍﻡ ﺃﻭ‬,‫ﺗﻀﺨﻢ ﺍﻟﺒﺮﻭﺳﺘﺎﺗﺎ ﺍﻟﺤﻤﻴﺪ‬,‫ ﺃﻭﺭﺍﻡ ﺍﻟﺮﺣﻢ ﺍﻟﻠﻴﻔﻰ‬, ‫ﺍﻻﻭﺭﺍﻡ ﺍﻟﺤﻤﻴﺪﺓ ﺍﻟﺘﺎﻟﻴﺔ )ﺃﻭﺭﺍﻡ ﺍﻟﺜﺪﻯ‬,‫ﺍﻷﻭﺭﺍﻡ ﺍﻟﺴﺮﻃﺎﻧﻴﺔ‬,‫ﺍﻟﺘﻮﺣﺪ‬
thyroid goiter and parathyroid glands, live tumors, colon tumors). Malignant tumors, listed ‫ﺃﻣﺮﺍﺽ ﺍﻟﻘﻠﺐ ﺍﻟﺘﺎﻟﻴﺔ)ﺃﻣﺮﺍﺽ ﺷﺮﺍﻳﻴﻦ ﻭﺻﻤﺎﻣﺎﺕ ﺗﻀﺨﻢ ﺍﻟﻐﺪﺓ ﺍﻟﺪﺭﻗﻴﺔ‬, (‫ﺃﻭﺭﺍﻡ ﺍﻟﻘﻮﻟﻮﻥ‬, ‫ﻭﺃﻭﺭﺍﻡ ﺍﻻﻟﻜﺒﺪ‬,‫ﻭ ﺍﻟﺠﺎﺭ ﺍﻟﺪﺭﻗﻴﺔ‬
Cardiac diseases coronary and valve heart diseases, heart failure, cardiac fibrillation
myocardial infraction, heart clots). Chronic Hepatitis C. Gallstones Sever Kidney failure (stage
* * ‫ﺍﻻﻟﺘﻬﺎﺏ ﺍﻟﻜﺒﺪﻯ ﺍﻟﻔﻴﺮﻭﺳﻰ ﺍﻟﻤﺰﻣﻦ‬.( ‫ﺍﻟﺮﺟﻔﺎﻥ ﺍﻟﻘﻠﺒﻰ ﻭﺟﻠﻄﺎﺕ ﺍﻟﻘﻠﺐ‬, ‫ﻓﺸﻞ ﻋﻀﻠﺔ ﺍﻟﻘﻠﺐ‬, ‫ﺣﺼﻮﺍﺕ ﺍﻟﻤﺮﺍﺭﺓ ﺍﻟﻘﻠﺐ‬, ‫ﺝ ﻭﺳﻰ‬
,‫ ﺍﻟﺘﺮﺷﻴﺢ ﺍﻟﻜﻠﻮﻯ ﺃﻗﻞ ﻣﻦ‬,‫ ﺍﻟﻔﺸﻞ ﺍﻟﻜﻠﻮﻯﺍﻟﺸﺪﻳﺪ )ﺍﻟﻤﺮﺣﻠﺔ ﺍﻟﺨﺎﻣﺴﺔ ﻣﻦ ﺍﻣﺮﺍﺽ ﺍﻟﻜﻠﻰ ﺍﻟﺘﻰ ﺗﺴﺘﺪﻋﻰ ﺍﻟﻐﺴﻴﻞ ﺍﻟﻜﻠﻮﻯ‬15
5 Requiring dialysis, clearance of less tha 15 ml/ minute*). Urinary tract ‫ﻣﺮﺽ‬, ‫ﺩﻗﻴﻘﺔ(ﺣﺼﻮﺍﺕ ﺍﻟﻤﺴﺎﻟﻚ ﺍﻟﺒﻮﻟﻴﺔﺃﻣﺮﺍﺽ ﺍﻟﻤﻨﺎﻋﺔ ﺍﻟﺘﺎﻟﻴﺔ )ﺍﻟﺬﺋﺒﺔ ﺍﻟﺤﻤﺮﺍﺀﻭﺍﻟﺘﻬﺎﺏ ﺍﻟﻤﻔﺎﺻﻞ ﺍﻟﺮﻭﻣﺎﺗﻴﺰﻣﻴﺔﻭ ﺍﻟﺼﺪﻓﻴﺔ‬/‫ﻣﻞ‬
stones, hernias. Autoimmune disease (lupus, rheumatoid arthritis, psoriasis, Crohn's disease, ‫ﺍﻟﺘﻬﺎﺏ ﺍﻟﻘﻮﻟﻮﻥ ﺍﻟﺘﻘﺮﺣﻰ‬, ‫ﻛﺮﻭﻧﺰ‬,
ulcerative colitis,multiple sclerosis, celiac disease) ‫ﺣﺴﺎﺳﻴﺔ ﺍﻟﻘﻤﺢ‬, ‫ﺍﻟﺘﺼﻠﺐ ﺍﻟﻠﻮﻳﺤﻰ‬

Have you been diagnosed with any of the following congenital disorder or
hereditary diseases limited to: Cerebral palsy, Sickle cell disorder, Thalassemia, ‫ﻫﻞ ﺗﻢ ﺗﺸﺨﻴﺼﻚ ﺑﺄﻱ ﻣﻦ ﺍﻷﻣﺮﺍﺽ ﺍﻟﻮﺭﺍﺛﻴﺔ ﺃﻭ ﺍﻟﺘﺸﻮﻫﺎﺕ ﺍﻟﺨﻠﻘﻴﺔ ﺍﻟﺘﺎﻟﻴﺔ ﻓﻘﻂ‬
hemophilia, metabolic diseases, Hydrocephalus, spinal muscle atrophy, genital ‫ ﺿﻤﻮﺭ‬،‫ ﺃﺳﺘﺴﻘﺎﺀ ﺍﻟﺮﺃﺱ‬،‫ ﺃﻣﺮﺍﺽ ﺍﻟﺘﻤﺜﻴﻞ ﺍﻟﻐﺬﺍﺋﻲ‬،‫ ﺍﻟﻬﻴﻤﻮﻓﻴﻠﻴﺎ‬،‫ ﺍﻟﺘﻼﺳﻴﻤﻴﺎ‬،‫ﺍﺿﻄﺮﺍﺏ ﺍﻟﺨﻼﻳﺎ ﺍﻟﻤﻨﺠﻠﻴﺔ‬, ‫ﺍﻟﺸﻠﻞ ﺍﻟﺪﻣﺎﻏﻰ‬
malformations, chromosomal abnormalities. Gaucher's disease, G6PD Deficiency, cystic
fibrosis, hemochromatosis, Wilson disease. Polycystic Kidney Disease.
* * ‫ ﻣﺮﺽ ﺍﻟﺘﻜﺴﺮﺍﻟﻔﻮﻟﻰ‬،‫ ﻣﺮﺽ ﻏﻮﺷﺮ‬،‫ ﺃﻣﺮﺍﺽ ﺍﻟﻜﺮﻭﻣﻮﺳﻮﻣﺎﺕ‬،‫ ﺗﺸﻮﻫﺎﺕ ﺍﻷﻋﻀﺎﺀ ﺍﻟﺘﻨﺎﺳﻠﻴﺔ‬،‫ﺍﻟﻌﻀﻼﺕ ﺍﻟﺸﻮﻛﻲ‬
‫ﺗﻜﻴﺲ‬,‫ﻣﺮﺽ ﻭﻳﻠﺴﻮﻥ‬, (‫ ﻣﺮﺽ ﺗﻜﺪﺱ ﺍﻟﺤﺪﻳﺪ )ﻫﻴﻤﻮﻛﺮﻭﻣﺎﺗﻮﺳﻴﺲ‬،‫( ﺍﻟﺘﻠﻴﻒ ﺍﻟﻜﻴﺴﻲ ﻟﻠﺮﺋﺔ‬G6PD)
‫ﺍﻟﻜﻠﻴﺘﻴﻦ ﺍﻟﺨﻠﻔﻰ ﺍﻟﻮﺭﺍﺋﻰ‬

Have you been diagnosed with any of following eye diseases limited to: ،‫ ﻣﻴﺎﺓ ﺯﺭﻗﺎﺀ‬،‫ ﻣﻴﺎﺓ ﺑﻴﻀﺎﺀ‬:‫ﻫﻞ ﺗﻢ ﺗﺸﺨﻴﺼﻚ ﺑﺄﻱ ﻣﻦ ﺃﻣﺮﺍﺽ ﺍﻟﻌﻴﻦ ﺍﻟﺘﺎﻟﻴﺔ ﻓﻘﻂ‬
Cataract, Glaucoma, Retinal diseases. * * ‫ﺃﻣﺮﺍﺽ ﺍﻟﺸﺒﻜﻴﺔ‬
Have you been diagnosed with any of the following bone diseases limited ‫ ﺍﻹﻧﺰﻻﻕ ﺍﻟﻐﻀﺮﻭﻓﻲ‬:‫ﻫﻞ ﺗﻢ ﺗﺸﺨﻴﺼﻚ ﺑﺄﻱ ﻣﻦ ﺃﻣﺮﺍﺽ ﺍﻟﻌﻈﺎﻡ ﺍﻟﺘﺎﻟﻴﺔ ﻓﻘﻂ‬
to:Vertebral disc prolapse (moderate or severe), Scoliosis (moderate or severe)**, or ligament
tears, osteoarthritis (moderate or severe )
* * ‫ﺗﻤﺰﻕ ﺍﻷﺭﺑﻄﺔ‬،‫ﺍﻟﺘﻬﺎﺏ ﺍﻟﻤﻔﺎﺻﻞ‬،‫ﺇﻧﺤﺮﺍﻑ ﺍﻟﻌﻤﻮﺩ ﺍﻟﻔﻘﺮﻱ‬,‫ﺍﻟﺪﻳﺴﻚ‬

Pregnant Female Only ‫ﻟﻸﻧﺜﻰ ﺍﻟﺤﺎﻣﻞ ﻓﻘﻂ‬

‫ﺣﻤﻞ ﺣﺎﻟﻲ ﺟﻨﻴﻦ ﻭﺍﺣﺪ‬
Current Single Pregnancy
* *
‫ﺣﻤﻞ ﺣﺎﻟﻲ ﻣﻊ ﻗﻴﺼﺮﻳﺔ ﺳﺎﺑﻘﺔ‬
Current Single Pregnancy with Previous CS Delivery
* *
‫ﺣﻤﻞ ﺣﺎﻟﻲ ﻣﺘﻌﺪﺩ ﺍﻷﺟﻨﺔ‬
Current Multiple Pregnancy
* *
Expected delivery date .. / .. / .... ‫ﺗﺎﺭﻳﺦ ﺍﻟﻮﻻﺩﺓ ﺍﻟﻤﺘﻮﻗﻊ‬
Employee and dependents details that need to be added ‫ﺑﻴﺎﻧﺎﺕ ﺍﻟﻤﻮﻇﻒ ﻭﺃﻓﺮﺍﺩ ﺍﻟﻌﺎﺋﻠﺔ ﺍﻟﻤﺮﺍﺩ ﺇﺿﺎﻓﺘﻬﻢ‬
In case of a yes answer above, please declare the case in the table below ‫ ﺍﻟﺮﺟﺎﺀ ﺫﻛﺮ ﺍﻟﺤﺎﻟﺔ ﻓﻲ ﺍﻟﺠﺪﻭﻝ ﺃﺩﻧﺎﻩ‬،‫ﻓﻲ ﺣﺎﻟﺔ ﺍﻹﺟﺎﺑﺔ ﺑﻨﻌﻢ ﺃﻋﻼﻩ‬
‫ﺇﺳﻢ ﻣﻘﺪﻡ ﺍﻟﺨﺪﻣﺔ‬ ‫ﺍﻟﺤﺎﻟﺔ‬ ‫ﺭﻗﻢ ﺍﻟﺠﻮﺍﻝ‬ ‫ﺍﻟﻄﻮﻝ‬ ‫ﺍﻟﻮﺯﻥ‬ ‫ﺭﻗﻢ ﺍﻟﻬﻮﻳﺔ‬ ‫ﺍﻟﻘﺮﺍﺑﺔ‬ ‫ﺍﻟﺠﻨﺲ‬ ‫ ﺃﻓﺮﺍﺩ ﺍﻟﻌﺎﺋﻠﺔ‬/ ‫ﺍﺳﻢ ﺍﻟﻤﻮﻇﻒ‬ ‫ﻡ‬
2326655491 Employee Male / ‫ ﺫﻛﺮ‬Muhammad Saleh Abdul Ghaf 1
2
3
4
5
Undertakings : ‫ﺍﻹﻗﺮﺍﺭ ﻭﺍﻟﺘﻔﻮﻳﺾ‬
1- I hereby undertake that all the above information is correct and the acceptance of my ‫ﻭﺍﻟﻤﻌﻠﻮﻣﺎﺕ ﺍﻟﻤﺬﻛﻮﺭﺓ ﺃﻋﻼﻩ ﻛﺎﻣﻠﺔ ﻭﺻﺤﻴﺤﺔ ﻭﺑﻨﺎﺀ ﻋﻠﻴﻪ ﻓﺈﻥ ﻗﺒﻮﻝ ﺍﻟﻄﻠﺐ ﺳﻴﺘﻢ‬: ‫ ﺃﻗﺮ ﺃﻥ ﺍﻟﺒﻴﺎﻧﺎﺕ‬-1
enrollment will be on the basis of such information and that Malath Cooperative Insurance ‫ﻋﻠﻰ ﺃﺳﺎﺱ ﻫﺬﻩ ﺍﻟﺒﻴﺎﻧﺎﺕ ﻭﺃﻥ ﺷﺮﻛﺔ ﻣﻼﺫ ﻟﻠﺘﺄﻣﻴﻦ ﺍﻟﺘﻌﺎﻭﻧﻲ ﻟﻬﺎ ﺍﻟﺤﻖ ﻓﻲ ﺍﻻﺗﺼﺎﻝ ﺑﺎﻟﻤﺴﺘﺸﻔﻴﺎﺕ ﺍﻟﺘﻲ‬
Company has the right to contact the hospital(s) I deal with to collect any ‫ﺃﺗﻌﺎﻣﻞ ﻣﻌﻬﺎ ﻟﺘﺰﻭﻳﺪﻫﺎ ﺑﺄﻱ ﻣﻌﻠﻮﻣﺎﺕ ﻃﺒﻴﺔ ﻗﺪ ﺗﺤﺘﺎﺝ ﺇﻟﻴﻬﺎ ﻟﺘﻘﻴﻴﻢ ﺍﻟﻤﺨﺎﻃﺮ‬
medical information needed to assess the risk(s).

2- I agree that Malath Cooperative Insurance Company has the right to reject the ‫ ﺃﻭﺍﻓﻖ ﻋﻠﻰ ﺃﺣﻘﻴﺔ ﺷﺮﻛﺔ ﻣﻼﺫ ﻟﻠﺘﺄﻣﻴﻦ ﻓﻲ ﺭﻓﺾ ﺍﻟﻤﻄﺎﻟﺒﺔ ﺃﻭ ﺍﻟﺘﻐﻄﻴﺔ ﻛﻠﻴﺎ ﻋﻨﺪ ﻋﺪﻡ ﺍﻹﻓﺼﺎﺡ ﻋﻦ ﻭﺟﻮﺩ ﺃﻱ ﻣﻦ ﺍﻟﺤﺎﻻﺕ‬-2
coverage/claims in full in case of no declaration of any cases prior to the contractual date or ‫ﺍﻟﻤﺬﻛﻮﺭﺓ ﺃﻋﻼﻩ ﺍﻟﺘﻲ ﻧﺸﺄﺕ ﻗﺒﻞ ﺗﺎﺭﻳﺦ ﺍﻟﺘﻌﺎﻗﺪ ﺃﻭ ﻗﺒﻞ ﺗﺴﺠﻴﻞ ﺃﻭ ﺇﺿﺎﻓﺔ ﻋﻀﻮ ﺧﻼﻝ ﻓﺘﺮﺓ ﺳﺮﻳﺎﻥ ﺍﻟﻌﻘﺪ‬
before enrolling or adding a new member during the contract.

3- I hereby confirm reading and understanding all points presented in this form and I agree that ‫ ﺃﻗﺮﺑﺄﻧﻲ ﻗﺪ ﻗﺮﺃﺕ ﻭﻓﻬﻤﺖ ﺟﻤﻴﻊ ﻣﺎ ﺟﺎﺀ ﻓﻲ ﻫﺬﺍ ﺍﻟﻨﻤﻮﺫﺝ ﻛﻤﺎ ﺃﺗﻌﻬﺪ ﺑﺄﻥ ﻋﺪﻡ ﺇﺷﺎﺭﺗﻲ ﺃﻣﺎﻡ ﺃﻱ ﻣﻦ‬-3
not marking any case is understood as “Nothing requires declaration” and I sign on these ‫ﺍﻟﺤﺎﻻﺕ ﺍﻟﻤﺬﻛﻮﺭﺓ ﺃﻋﻼﻩ ﻳﻌﺘﺒﺮ ﺑﻤﺜﺎﺑﺔ ﻧﻔﻲ ﻭﺟﻮﺩ ﻣﺎﻳﺴﺘﺤﻖ ﺍﻹﻓﺼﺎﺡ ﻋﻨﻪ ﻭﻋﻠﻴﻪ ﺃﻭﻗﻊ‬
basis.
4- Failure to fill the weight and height information will result in refusal to cover
the cost of obesity surgery. ‫ ﻋﺪﻡ ﺗﻌﺒﺌﺔ ﺑﻴﺎﻧﺎﺕ ﺍﻟﻄﻮﻝ ﻭﺍﻟﻮﺯﻥ ﺳﻴﺆﺩﻱ ﺇﻟﻰ ﺭﻓﺾ ﺗﻐﻄﻴﺔ ﺗﻜﺎﻟﻴﻒ ﻋﻤﻠﻴﺔ ﺟﺮﺍﺣﺔ ﺍﻟﺴﻤﻨﺔ ﺍﻟﻤﻔﺮﻃﺔ‬-4

Entity's stamp ‫ﺧﺘﻢ ﺟﻬﺔ ﺍﻟﻌﻤﻞ‬ Insured Signature ‫ﺗﻮﻗﻴﻊ ﺍﻟﻤﻮﻇﻒ‬ Date ‫ﺍﻟﺘﺎﺭﻳﺦ‬
.. / .. / ....

New_Health_Insurance.rdf Page 38 of 39 V.20 13-DEC-2023 01:30 PM

 ‫ﻧﻤﻮﺫﺝ ﺍﻻﻓﺼﺎﺡ ﺍﻟﻄﺒﻲ ﺍﻟﻤﻮﺣﺪ‬
Unified Medical Declaration Form
Product Code: A-MLTH-2-C-08-014
Dear Insured: ‫ﻋﺰﻳﺰﻱ ﺍﻟﻤﺆﻣﻦ ﻟﻪ‬
Please Fill out the form correctly for the purpose of pricing and to ensured that you and your ‫ﻧﺄﻣﻞ ﻗﻴﺎﻣﻚ ﺑﺘﻌﺒﺌﺔ ﻫﺬﺍ ﺍﻟﻨﻤﻮﺫﺝ ﺑﺎﻟﺸﻜﻞ ﺍﻟﺼﺤﻴﺢ ﻟﻐﺮﺽ ﺍﻟﺘﺴﻌﻴﺮ ﻭﻟﻀﻤﺎﻥ ﺣﺼﻮﻟﻚ ﻭﺃﻓﺮﺍﺩ ﺃﺳﺮﺗﻚ ﻋﻠﻰ ﺧﺪﻣﺎﺕ‬
family receive health care services as required according to your unfied policy benefit ‫ﺍﻟﺮﻋﺎﻳﺔ ﺍﻟﺼﺤﻴﺔ ﺑﺎﻟﺸﻜﻞ ﺍﻟﻤﻄﻠﻮﺏ ﺣﺴﺐ ﻣﻨﺎﻓﻊ ﺍﻟﻮﺛﻴﻘﺔ ﺍﻟﻤﻮﺣﺪﺓ‬

Addition ‫ﺇﺿﺎﻓﺔ‬ New ‫ﺟﺪﻳﺪ‬ Type ‫ﻧﻮﻉ ﺍﻟﻄﻠﺐ‬

CR No 7011507360 ‫ﺍﻟﺴﺠﻞ ﺍﻟﺘﺠﺎﺭﻱ‬ Entity Name HADDAJ AL HIJAZ EST ‫ﺃﺳﻢ ﺍﻟﻤﻨﺸﺄﺓ‬
Mobile No 0554663975 ‫ﺭﻗﻢ ﺍﻟﺠﻮﺍﻝ‬ Mohashin Ali Abdul Malitha ‫ﺍﺳﻢ ﺍﻟﻤﻮﻇﻒ‬
ID Number 2 4 7 8 0 8 1 2 1 5 ‫ﺭﻗﻢ ﺍﻟﻬﻮﻳﺔ‬
Male / ‫ﺫﻛﺮ‬ Bangladesh
Gender ‫ ﺍﻟﺠﻨﺲ‬Nationality ‫ ﺍﻟﺠﻨﺴﻴﺔ‬Marital status Married R ‫ﻣﺘﺰﻭﺝ‬ Single * ‫ﺃﻋﺰﺏ‬ ‫ﺍﻟﺤﺎﻟﺔ ﺍﻻﺟﺘﻤﺎﻋﻴﺔ‬
Please declare any of the below cases by marking P under the word Yes ‫ ﻓﻲ ﺍﻟﻤﺮﺑﻊ ﺗﺤﺖ ﻛﻠﻤﺔ ﻧﻌﻢ‬P ‫ﻳﺮﺟﻰ ﺍﻹﻓﺼﺎﺡ ﻋﻦ ﻭﺟﻮﺩ ﺃﻱ ﻣﻦ ﺍﻟﺤﺎﻻﺕ ﺍﺩﻧﺎﻩ ﺑﻮﺿﻊ ﺇﺷﺎﺭﺓ‬
"Below Undeclared Medical Case May Not Be Covered" No / ‫ﻻ‬ Yes / ‫ﻧﻌـﻢ‬ "‫"ﻟﻦ ﺗﺘﻢ ﺍﻟﺘﻐﻄﻴﺔ ﺍﻟﺘﺄﻣﻴﻨﻴﺔ ﻟﻠﺤﺎﻻﺕ ﺃﺩﻧﺎﻩ ﻓﻰ ﺣﺎﻝ ﻋﺪﻡ ﺍﻹﻓﺼﺎﺡ ﻋﻨﻬﺎ‬
Any hospital admission during last 12 months. ‫ ﺷﻬﺮ‬12 ‫ﻫﻞ ﺗﻢ ﺍﻟﺘﻨﻮﻳﻢ ﺑﺎﻟﻤﺴﺘﺸﻔﻰ ﺧﻼﻝ ﺃﺧﺮ‬
"Admission: registering as an admitted patient at the hospital until the following morning "
* * " ‫ ﺗﺴﺠﻴﻞ ﺍﻟﺸﺨﺺ ﺍﻟﻤﺆﻣﻦ ﻟﻪ ﻛﻤﺮﻳﺾ ﻣﻨﻮﻡ ﻓﻲ ﺍﻟﻤﺴﺘﺸﻔﻰ ﺣﺘﻰ ﺻﺒﺎﺡ ﺍﻟﻴﻮﻡ ﺍﻟﺘﺎﻟﻲ‬: ‫" ﺍﻟﺘﻨﻮﻳﻢ‬

Have you been diagnosed with any of the following chronic disease limited ‫ﻫﻞ ﺗﻢ ﺗﺸﺨﻴﺼﻚ ﺑﺄﻯ ﻣﻦ ﺍﻷﻣﺮﺍﺽ ﺍﻟﺘﺎﻟﻴﺔ ﻓﻘﻂ‬
to:Autism, listed Benign Tumor (Breast tumors, fibroid uterus, benign prostatic hyperplasia, ‫ﺃﻭﺭﺍﻡ ﺃﻭ‬,‫ﺗﻀﺨﻢ ﺍﻟﺒﺮﻭﺳﺘﺎﺗﺎ ﺍﻟﺤﻤﻴﺪ‬,‫ ﺃﻭﺭﺍﻡ ﺍﻟﺮﺣﻢ ﺍﻟﻠﻴﻔﻰ‬, ‫ﺍﻻﻭﺭﺍﻡ ﺍﻟﺤﻤﻴﺪﺓ ﺍﻟﺘﺎﻟﻴﺔ )ﺃﻭﺭﺍﻡ ﺍﻟﺜﺪﻯ‬,‫ﺍﻷﻭﺭﺍﻡ ﺍﻟﺴﺮﻃﺎﻧﻴﺔ‬,‫ﺍﻟﺘﻮﺣﺪ‬
thyroid goiter and parathyroid glands, live tumors, colon tumors). Malignant tumors, listed ‫ﺃﻣﺮﺍﺽ ﺍﻟﻘﻠﺐ ﺍﻟﺘﺎﻟﻴﺔ)ﺃﻣﺮﺍﺽ ﺷﺮﺍﻳﻴﻦ ﻭﺻﻤﺎﻣﺎﺕ ﺗﻀﺨﻢ ﺍﻟﻐﺪﺓ ﺍﻟﺪﺭﻗﻴﺔ‬, (‫ﺃﻭﺭﺍﻡ ﺍﻟﻘﻮﻟﻮﻥ‬, ‫ﻭﺃﻭﺭﺍﻡ ﺍﻻﻟﻜﺒﺪ‬,‫ﻭ ﺍﻟﺠﺎﺭ ﺍﻟﺪﺭﻗﻴﺔ‬
Cardiac diseases coronary and valve heart diseases, heart failure, cardiac fibrillation
myocardial infraction, heart clots). Chronic Hepatitis C. Gallstones Sever Kidney failure (stage
* * ‫ﺍﻻﻟﺘﻬﺎﺏ ﺍﻟﻜﺒﺪﻯ ﺍﻟﻔﻴﺮﻭﺳﻰ ﺍﻟﻤﺰﻣﻦ‬.( ‫ﺍﻟﺮﺟﻔﺎﻥ ﺍﻟﻘﻠﺒﻰ ﻭﺟﻠﻄﺎﺕ ﺍﻟﻘﻠﺐ‬, ‫ﻓﺸﻞ ﻋﻀﻠﺔ ﺍﻟﻘﻠﺐ‬, ‫ﺣﺼﻮﺍﺕ ﺍﻟﻤﺮﺍﺭﺓ ﺍﻟﻘﻠﺐ‬, ‫ﺝ ﻭﺳﻰ‬
,‫ ﺍﻟﺘﺮﺷﻴﺢ ﺍﻟﻜﻠﻮﻯ ﺃﻗﻞ ﻣﻦ‬,‫ ﺍﻟﻔﺸﻞ ﺍﻟﻜﻠﻮﻯﺍﻟﺸﺪﻳﺪ )ﺍﻟﻤﺮﺣﻠﺔ ﺍﻟﺨﺎﻣﺴﺔ ﻣﻦ ﺍﻣﺮﺍﺽ ﺍﻟﻜﻠﻰ ﺍﻟﺘﻰ ﺗﺴﺘﺪﻋﻰ ﺍﻟﻐﺴﻴﻞ ﺍﻟﻜﻠﻮﻯ‬15
5 Requiring dialysis, clearance of less tha 15 ml/ minute*). Urinary tract ‫ﻣﺮﺽ‬, ‫ﺩﻗﻴﻘﺔ(ﺣﺼﻮﺍﺕ ﺍﻟﻤﺴﺎﻟﻚ ﺍﻟﺒﻮﻟﻴﺔﺃﻣﺮﺍﺽ ﺍﻟﻤﻨﺎﻋﺔ ﺍﻟﺘﺎﻟﻴﺔ )ﺍﻟﺬﺋﺒﺔ ﺍﻟﺤﻤﺮﺍﺀﻭﺍﻟﺘﻬﺎﺏ ﺍﻟﻤﻔﺎﺻﻞ ﺍﻟﺮﻭﻣﺎﺗﻴﺰﻣﻴﺔﻭ ﺍﻟﺼﺪﻓﻴﺔ‬/‫ﻣﻞ‬
stones, hernias. Autoimmune disease (lupus, rheumatoid arthritis, psoriasis, Crohn's disease, ‫ﺍﻟﺘﻬﺎﺏ ﺍﻟﻘﻮﻟﻮﻥ ﺍﻟﺘﻘﺮﺣﻰ‬, ‫ﻛﺮﻭﻧﺰ‬,
ulcerative colitis,multiple sclerosis, celiac disease) ‫ﺣﺴﺎﺳﻴﺔ ﺍﻟﻘﻤﺢ‬, ‫ﺍﻟﺘﺼﻠﺐ ﺍﻟﻠﻮﻳﺤﻰ‬

Have you been diagnosed with any of the following congenital disorder or
hereditary diseases limited to: Cerebral palsy, Sickle cell disorder, Thalassemia, ‫ﻫﻞ ﺗﻢ ﺗﺸﺨﻴﺼﻚ ﺑﺄﻱ ﻣﻦ ﺍﻷﻣﺮﺍﺽ ﺍﻟﻮﺭﺍﺛﻴﺔ ﺃﻭ ﺍﻟﺘﺸﻮﻫﺎﺕ ﺍﻟﺨﻠﻘﻴﺔ ﺍﻟﺘﺎﻟﻴﺔ ﻓﻘﻂ‬
hemophilia, metabolic diseases, Hydrocephalus, spinal muscle atrophy, genital ‫ ﺿﻤﻮﺭ‬،‫ ﺃﺳﺘﺴﻘﺎﺀ ﺍﻟﺮﺃﺱ‬،‫ ﺃﻣﺮﺍﺽ ﺍﻟﺘﻤﺜﻴﻞ ﺍﻟﻐﺬﺍﺋﻲ‬،‫ ﺍﻟﻬﻴﻤﻮﻓﻴﻠﻴﺎ‬،‫ ﺍﻟﺘﻼﺳﻴﻤﻴﺎ‬،‫ﺍﺿﻄﺮﺍﺏ ﺍﻟﺨﻼﻳﺎ ﺍﻟﻤﻨﺠﻠﻴﺔ‬, ‫ﺍﻟﺸﻠﻞ ﺍﻟﺪﻣﺎﻏﻰ‬
malformations, chromosomal abnormalities. Gaucher's disease, G6PD Deficiency, cystic
fibrosis, hemochromatosis, Wilson disease. Polycystic Kidney Disease.
* * ‫ ﻣﺮﺽ ﺍﻟﺘﻜﺴﺮﺍﻟﻔﻮﻟﻰ‬،‫ ﻣﺮﺽ ﻏﻮﺷﺮ‬،‫ ﺃﻣﺮﺍﺽ ﺍﻟﻜﺮﻭﻣﻮﺳﻮﻣﺎﺕ‬،‫ ﺗﺸﻮﻫﺎﺕ ﺍﻷﻋﻀﺎﺀ ﺍﻟﺘﻨﺎﺳﻠﻴﺔ‬،‫ﺍﻟﻌﻀﻼﺕ ﺍﻟﺸﻮﻛﻲ‬
‫ﺗﻜﻴﺲ‬,‫ﻣﺮﺽ ﻭﻳﻠﺴﻮﻥ‬, (‫ ﻣﺮﺽ ﺗﻜﺪﺱ ﺍﻟﺤﺪﻳﺪ )ﻫﻴﻤﻮﻛﺮﻭﻣﺎﺗﻮﺳﻴﺲ‬،‫( ﺍﻟﺘﻠﻴﻒ ﺍﻟﻜﻴﺴﻲ ﻟﻠﺮﺋﺔ‬G6PD)
‫ﺍﻟﻜﻠﻴﺘﻴﻦ ﺍﻟﺨﻠﻔﻰ ﺍﻟﻮﺭﺍﺋﻰ‬

Have you been diagnosed with any of following eye diseases limited to: ،‫ ﻣﻴﺎﺓ ﺯﺭﻗﺎﺀ‬،‫ ﻣﻴﺎﺓ ﺑﻴﻀﺎﺀ‬:‫ﻫﻞ ﺗﻢ ﺗﺸﺨﻴﺼﻚ ﺑﺄﻱ ﻣﻦ ﺃﻣﺮﺍﺽ ﺍﻟﻌﻴﻦ ﺍﻟﺘﺎﻟﻴﺔ ﻓﻘﻂ‬
Cataract, Glaucoma, Retinal diseases. * * ‫ﺃﻣﺮﺍﺽ ﺍﻟﺸﺒﻜﻴﺔ‬
Have you been diagnosed with any of the following bone diseases limited ‫ ﺍﻹﻧﺰﻻﻕ ﺍﻟﻐﻀﺮﻭﻓﻲ‬:‫ﻫﻞ ﺗﻢ ﺗﺸﺨﻴﺼﻚ ﺑﺄﻱ ﻣﻦ ﺃﻣﺮﺍﺽ ﺍﻟﻌﻈﺎﻡ ﺍﻟﺘﺎﻟﻴﺔ ﻓﻘﻂ‬
to:Vertebral disc prolapse (moderate or severe), Scoliosis (moderate or severe)**, or ligament
tears, osteoarthritis (moderate or severe )
* * ‫ﺗﻤﺰﻕ ﺍﻷﺭﺑﻄﺔ‬،‫ﺍﻟﺘﻬﺎﺏ ﺍﻟﻤﻔﺎﺻﻞ‬،‫ﺇﻧﺤﺮﺍﻑ ﺍﻟﻌﻤﻮﺩ ﺍﻟﻔﻘﺮﻱ‬,‫ﺍﻟﺪﻳﺴﻚ‬

Pregnant Female Only ‫ﻟﻸﻧﺜﻰ ﺍﻟﺤﺎﻣﻞ ﻓﻘﻂ‬

‫ﺣﻤﻞ ﺣﺎﻟﻲ ﺟﻨﻴﻦ ﻭﺍﺣﺪ‬
Current Single Pregnancy
* *
‫ﺣﻤﻞ ﺣﺎﻟﻲ ﻣﻊ ﻗﻴﺼﺮﻳﺔ ﺳﺎﺑﻘﺔ‬
Current Single Pregnancy with Previous CS Delivery
* *
‫ﺣﻤﻞ ﺣﺎﻟﻲ ﻣﺘﻌﺪﺩ ﺍﻷﺟﻨﺔ‬
Current Multiple Pregnancy
* *
Expected delivery date .. / .. / .... ‫ﺗﺎﺭﻳﺦ ﺍﻟﻮﻻﺩﺓ ﺍﻟﻤﺘﻮﻗﻊ‬
Employee and dependents details that need to be added ‫ﺑﻴﺎﻧﺎﺕ ﺍﻟﻤﻮﻇﻒ ﻭﺃﻓﺮﺍﺩ ﺍﻟﻌﺎﺋﻠﺔ ﺍﻟﻤﺮﺍﺩ ﺇﺿﺎﻓﺘﻬﻢ‬
In case of a yes answer above, please declare the case in the table below ‫ ﺍﻟﺮﺟﺎﺀ ﺫﻛﺮ ﺍﻟﺤﺎﻟﺔ ﻓﻲ ﺍﻟﺠﺪﻭﻝ ﺃﺩﻧﺎﻩ‬،‫ﻓﻲ ﺣﺎﻟﺔ ﺍﻹﺟﺎﺑﺔ ﺑﻨﻌﻢ ﺃﻋﻼﻩ‬
‫ﺇﺳﻢ ﻣﻘﺪﻡ ﺍﻟﺨﺪﻣﺔ‬ ‫ﺍﻟﺤﺎﻟﺔ‬ ‫ﺭﻗﻢ ﺍﻟﺠﻮﺍﻝ‬ ‫ﺍﻟﻄﻮﻝ‬ ‫ﺍﻟﻮﺯﻥ‬ ‫ﺭﻗﻢ ﺍﻟﻬﻮﻳﺔ‬ ‫ﺍﻟﻘﺮﺍﺑﺔ‬ ‫ﺍﻟﺠﻨﺲ‬ ‫ ﺃﻓﺮﺍﺩ ﺍﻟﻌﺎﺋﻠﺔ‬/ ‫ﺍﺳﻢ ﺍﻟﻤﻮﻇﻒ‬ ‫ﻡ‬
2478081215 Employee Male / ‫ ﺫﻛﺮ‬Mohashin Ali Abdul Malitha 1
2
3
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5
Undertakings : ‫ﺍﻹﻗﺮﺍﺭ ﻭﺍﻟﺘﻔﻮﻳﺾ‬
1- I hereby undertake that all the above information is correct and the acceptance of my ‫ﻭﺍﻟﻤﻌﻠﻮﻣﺎﺕ ﺍﻟﻤﺬﻛﻮﺭﺓ ﺃﻋﻼﻩ ﻛﺎﻣﻠﺔ ﻭﺻﺤﻴﺤﺔ ﻭﺑﻨﺎﺀ ﻋﻠﻴﻪ ﻓﺈﻥ ﻗﺒﻮﻝ ﺍﻟﻄﻠﺐ ﺳﻴﺘﻢ‬: ‫ ﺃﻗﺮ ﺃﻥ ﺍﻟﺒﻴﺎﻧﺎﺕ‬-1
enrollment will be on the basis of such information and that Malath Cooperative Insurance ‫ﻋﻠﻰ ﺃﺳﺎﺱ ﻫﺬﻩ ﺍﻟﺒﻴﺎﻧﺎﺕ ﻭﺃﻥ ﺷﺮﻛﺔ ﻣﻼﺫ ﻟﻠﺘﺄﻣﻴﻦ ﺍﻟﺘﻌﺎﻭﻧﻲ ﻟﻬﺎ ﺍﻟﺤﻖ ﻓﻲ ﺍﻻﺗﺼﺎﻝ ﺑﺎﻟﻤﺴﺘﺸﻔﻴﺎﺕ ﺍﻟﺘﻲ‬
Company has the right to contact the hospital(s) I deal with to collect any ‫ﺃﺗﻌﺎﻣﻞ ﻣﻌﻬﺎ ﻟﺘﺰﻭﻳﺪﻫﺎ ﺑﺄﻱ ﻣﻌﻠﻮﻣﺎﺕ ﻃﺒﻴﺔ ﻗﺪ ﺗﺤﺘﺎﺝ ﺇﻟﻴﻬﺎ ﻟﺘﻘﻴﻴﻢ ﺍﻟﻤﺨﺎﻃﺮ‬
medical information needed to assess the risk(s).

2- I agree that Malath Cooperative Insurance Company has the right to reject the ‫ ﺃﻭﺍﻓﻖ ﻋﻠﻰ ﺃﺣﻘﻴﺔ ﺷﺮﻛﺔ ﻣﻼﺫ ﻟﻠﺘﺄﻣﻴﻦ ﻓﻲ ﺭﻓﺾ ﺍﻟﻤﻄﺎﻟﺒﺔ ﺃﻭ ﺍﻟﺘﻐﻄﻴﺔ ﻛﻠﻴﺎ ﻋﻨﺪ ﻋﺪﻡ ﺍﻹﻓﺼﺎﺡ ﻋﻦ ﻭﺟﻮﺩ ﺃﻱ ﻣﻦ ﺍﻟﺤﺎﻻﺕ‬-2
coverage/claims in full in case of no declaration of any cases prior to the contractual date or ‫ﺍﻟﻤﺬﻛﻮﺭﺓ ﺃﻋﻼﻩ ﺍﻟﺘﻲ ﻧﺸﺄﺕ ﻗﺒﻞ ﺗﺎﺭﻳﺦ ﺍﻟﺘﻌﺎﻗﺪ ﺃﻭ ﻗﺒﻞ ﺗﺴﺠﻴﻞ ﺃﻭ ﺇﺿﺎﻓﺔ ﻋﻀﻮ ﺧﻼﻝ ﻓﺘﺮﺓ ﺳﺮﻳﺎﻥ ﺍﻟﻌﻘﺪ‬
before enrolling or adding a new member during the contract.

3- I hereby confirm reading and understanding all points presented in this form and I agree that ‫ ﺃﻗﺮﺑﺄﻧﻲ ﻗﺪ ﻗﺮﺃﺕ ﻭﻓﻬﻤﺖ ﺟﻤﻴﻊ ﻣﺎ ﺟﺎﺀ ﻓﻲ ﻫﺬﺍ ﺍﻟﻨﻤﻮﺫﺝ ﻛﻤﺎ ﺃﺗﻌﻬﺪ ﺑﺄﻥ ﻋﺪﻡ ﺇﺷﺎﺭﺗﻲ ﺃﻣﺎﻡ ﺃﻱ ﻣﻦ‬-3
not marking any case is understood as “Nothing requires declaration” and I sign on these ‫ﺍﻟﺤﺎﻻﺕ ﺍﻟﻤﺬﻛﻮﺭﺓ ﺃﻋﻼﻩ ﻳﻌﺘﺒﺮ ﺑﻤﺜﺎﺑﺔ ﻧﻔﻲ ﻭﺟﻮﺩ ﻣﺎﻳﺴﺘﺤﻖ ﺍﻹﻓﺼﺎﺡ ﻋﻨﻪ ﻭﻋﻠﻴﻪ ﺃﻭﻗﻊ‬
basis.
4- Failure to fill the weight and height information will result in refusal to cover
the cost of obesity surgery. ‫ ﻋﺪﻡ ﺗﻌﺒﺌﺔ ﺑﻴﺎﻧﺎﺕ ﺍﻟﻄﻮﻝ ﻭﺍﻟﻮﺯﻥ ﺳﻴﺆﺩﻱ ﺇﻟﻰ ﺭﻓﺾ ﺗﻐﻄﻴﺔ ﺗﻜﺎﻟﻴﻒ ﻋﻤﻠﻴﺔ ﺟﺮﺍﺣﺔ ﺍﻟﺴﻤﻨﺔ ﺍﻟﻤﻔﺮﻃﺔ‬-4

Entity's stamp ‫ﺧﺘﻢ ﺟﻬﺔ ﺍﻟﻌﻤﻞ‬ Insured Signature ‫ﺗﻮﻗﻴﻊ ﺍﻟﻤﻮﻇﻒ‬ Date ‫ﺍﻟﺘﺎﺭﻳﺦ‬
.. / .. / ....

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