Family Medical - Member Details

Member Details

Member Name	*	Gender	*
Relation to applicant	*	Date of birth	*

Medical History Declaration

Please answer the following questions, taking into consideration that in case you do not declare the medical facts fully, Tawuniya shall have the right to cancel the medical insurance coverage of the policyholder and/or insured (beneficiary) immediately. In addition, Tawuniya shall have the right to claim all expenses related to medical insurance coverage from the policyholder and/or the Insured (beneficiary), directly or indirectly:

Have you been admitted in any hospital or medical center during the past ten months?

Have you been diagnosed of any acute, chronic or dangerous disease? Including, for example, but not limited to: Cardiac diseases, chest diseases, arteriosclerosis, hypertension, high cholesterol, vascular diseases, diabetes mellitus, cancer, endocrine diseases, psychiatric disease, disability, failure of (heart, kidney, liver, respiratory system), biliary and gall balder diseases, prostate, bladder, urinary tract, reproductive system, muscle diseases, spinal cord, the digestive system, nervous system diseases, jaw, pharynx, tonsils and blood diseases, bone diseases, joint replacements and spine surgery, congenital deformity, and other.

(Applicable to wives only) Are you pregnant?

If the answer to any of the previous three questions is «Yes», please complete the following table, taking into consideration that Tawuniya may review the medical file of the person proposed for insurance (beneficiary), and then conduct a thorough medical examination for him / her, at the expense of the policyholder, in order to determine the appropriate amount of contribution for the person proposed for insurance (beneficiary).

Description of Illness/Disability	The Year in which the Illness/Disability Occurred	Name of the Hospital(private sector)	Present State of Health in Respect of this Illness/Disability	Hospital File No.

Please provide any other relevant information not mentioned

Is there any other information that utmost good faith requires to be disclosed?

If the answer to this question is «Yes», please explain:

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