Medical application for Groups

Important Note: The insurance company will not be responsible for this medical cover until we give the client our written agreement and we receive in return the firm order and the required premium from the client.
Section 1 : Information about the client

The client full name
Email
Nature of work
Are you currently insured?YesNo
If you are already insured kindly specify the Ex / Current insurance company name :
Section 2 : The client Address

The client address
Postal Address
Postal Code
Postal Box
City
Country
Fax
Tele No.
Section 3 : The requested cover

Kindly determine the required cover
Program L.E 10000Program L.E 20000Program L.E 30000Program L.E 50000Program L.E 750000Program L.E 100000Program L.E 1500000Other
Section 4 : Additional cover ( will be covered with extra premium )

Do you wish to obtain additional cover?

The maximum annual individual cover

According to the client request
According to the required prog
Kind for cover : Critical Disease
According to the client request
According to the required prog
Kind for cover : Chronic Disease
According to the client request
According to the required prog
Kind for cover : Pre-Existing Disease
According to the client request
According to the required prog
Kind for cover : Maternity
According to the client request
According to the required prog
Kind for cover : Dental
According to the client request
According to the required prog
Kind for cover : Optical
Section 5 : Claims history ( The last three years)

Loss Ratio
No of persons
Year
First Year
Second Year
Third Year
Section 6 : Personal Medical History ( In case of covering Pre-Existing and chronic disease )

No.
Details
Employee Name
1
2
3
4
5
6
Section 7 : Determine the no. of insured persons

Number of Employees
Number of Dependents
Section 8 : Data related to sex and age (Determine the total no. in each category)

Age
Main Application Male
Main Application Female
Dependents Male
Dependents Female
0-18
19-25
26-30
31-35
36-40
41-45
46-50
51-55
56-60
61-65
Section 9 : Data related to the client contact person

Name :
Tel / Fax :
Title :
Section 10 : Authorization

I am the undersigned person authorized on behalf of the company that all the data mentioned in this application are all true and complete and any false information will lead to breaching the contract and waste of any / all our rights in the claims introduced from our side, and i authorize that the insurance company will not responsible toward this application until we receive its written approval toward this application also until we receive the acceptance letter from it.
I delegate on behalf of the company the insurance company in searching for any medical information from any doctor, hospitals, clients, Pharmacies or any other insurance company regarding the medication or the diagnoses of any case.
I agree on behalf of the company That the medical application will be the base of the insurance contract in case of applying the insurance.
In case that the information or the answers or the details mentioned in the application are not true or incorrect after the starting of the insurance policy, the insurance company will not be legally responsible regarding this insurance.
Authorized Person :
Occupation :
Date :
Note: The Minimum Number To Be Medically Insured As Corporate Insurance Are 30 Persons.