Proposal Form Individual Health Insurance

Mahmoud S. Shalab
Medical Underwriting
PROPOSAL FORM
INDIVIDUAL MEDICAL INSURANCE

Please complete this form using BLOCK CAPITALS and by ticking the relevant items. Kindly enclose Passport copies and photographs of
the members to be insured. PLEASE ENCLOSE RELEVANT MEDICAL REPORTS FROM TREATING DOCTOR WITH
REGARD TO THE DECLARED AILMENTS.
1. Applicant’s Details ﻦﻴﻣﺄﺘﻟا ﺐﻟﺎﻃ ﻦﻋ تﺎﻣﻮﻠﻌﻣ .1

Name : Date of Birth : dd mm yy
ﺔﻨﺳ ﺮﻬﺷ مﻮﻳ : دﻼﻴﻤﻟا ﺦﻳرﺎﺗ ﻢﺳﻻا
Occupation : Nationality :
ﺔﻴﺴﻨﺠﻟا ﺔﻨﻬﻤﻟا
Gender
ﺲﻨﺠﻟا

Male
ﺮآذ

Female
ﻰﺜﻥأ

Height (cm)
لﻮﻄﻟا ) ﻢﺳ )

Weight (kg)
نزﻮﻟا ) ﺞآ )

Marital Status
ﺔﻴﻋﺎﻤﺘﺝﻻا ﺔﻟﺎﺤﻟا

Married
جوﺰﺘﻡ

Single
بﺰﻋأ

Divorced
ﻞﺼﻔﻨﻡ / ﻖﻠﻄﻡ
No. of Children
دﻻوﻷا دﺪﻋ

UAE Residents Only
ﻹا ﺔﻟود ﻞﺧاد ﻦﻴﻤﻴﻘﻤﻟا ﻂﻘﻓ تارﺎﻡ

2. Dependents’ Details. 2. ﻦﻴﻟﺎﻌﻤﻟا صﺎﺨﺷﻷا ﻞﻴﺻﺎﻔﺕ

Name of Dependent لﺎﻌﻤﻟا ﺺﺨﺸﻟا ﻢﺳا Relationship to Applicant Height (cm) Weight (kg) Date of Birth دﻼﻴﻤﻟا ﺦﻳرﺎﺗ
ﻦﻴﻡﺄﺘﻟا ﺐﻟﺎﻄﺑ ﻪﺘﻗﻼﻋ لﻮﻄﻟا نزﻮﻟا Day مﻮﻳ Month ﺮﻬﺷ Year ﺔﻨﺳ



















3. Address 3. ناﻮﻨﻌﻟا

Company Name: P.O. Box: Emirate: E-Mail:
ﻲﻥوﺮﺘﻜﻟﻹا ﺪﻳﺮﺒﻟا ةرﺎﻡﻹا ص . ب ﺔآﺮﺸﻟا ﻢﺳا
Phone : Work Res.: Fax:
ﺲآﺎﻓ لﺰﻨﻤﻟا ﻞﻤﻌﻟا : ﻢﻗر
ﻒﺗﺎﻬﻟا
4. (a) Geographical Coverage Required 4. ( أ ( ﺎﻬﺘﻴﻄﻐﺕ بﻮﻠﻄﻤﻟا ﺔﻴﻓاﺮﻐﺠﻟا ﺔﻘﻄﻨﻤﻟا

UAE only
ﻂﻘﻓ تارﺎﻡﻹا

UAE, GCC & Indian Sub-Continent
نوﺎﻌﺘﻟا ﺲﻠﺠﻡ لود ،تارﺎﻡﻹا – ﺔﻳﺪﻨﻬﻟا ةرﺎﻘﻟا ﺔﺒﺷو ﺪﻨﻬﻟا

UAE, GCC & Indian Sub-Count plus emergency treatment worldwide (ex. USA & Canada)
نوﺎﻌﺘﻟا ﺲﻠﺠﻡ لود ،تارﺎﻡﻹا + اﺪﻨآ و ﺎﻜﻳﺮﻡأ اﺪﻋ ﺎﻡ ﻢﻟﺎﻌﻟا لود ﻞآ ﻲﻓ ﺔﺋرﺎﻄﻟا تﻻﺎﺤﻟا

UAE, GCC & Indian Sub-Continent plus emergency treatment worldwide (including. USA & Canada)
نوﺎﻌﺘﻟا ﺲﻠﺠﻡ لود ،تارﺎﻡﻹا + اﺪﻨآ و ﺎﻜﻳﺮﻡأ ﻊﻡ ﻢﻟﺎﻌﻟا لود ﻞآ ﻲﻓ ﺔﺋرﺎﻄﻟا تﻻﺎﺤﻟا
(b) Network
ﺔﻜﺒﺸﻟا
OIC Restricted Network ةدوﺪﺤﻤﻟا ﺔﻜﺒﺸﻟا OIC Comprehensive Network ﺔﻠﻡﺎﺸﻟا ﺔﻜﺒﺸﻟا
5. Medical History 5. ﻲﺒﻄﻟا ﺦیرﺎﺘﻟا

a) Have you or any person you wish to insure sought medical advice, received medical treatment or suffered from any medical condition
(whether medical treatment or medical advice was given or not) other than for minor illness, during the last 24 months? If “Yes”
complete details in 5 (c)
أ) ﺔﻴﺤﺹ ﺔﻟﺎﺡ ﺔﻳأ ﻦﻡ ﻰﻥﺎﻋ وأ ﺔﻴﺒﻃ ﺔﺠﻟﺎﻌﻡ ﺔﻳأ جذﻮﻤﻨﻟا اﺬه ﻲﻓ ﻪﻤﺳا جرﺪﻡ ﺮﺧﺁ ﺺﺨﺷ يأ وأ ﺖﻥأ ﺖﻴﻘﻠﺗ ﻞه ) ﻢﺘﺗ ﻢﻟ مأ ﺎﻬﺘﺠﻟﺎﻌﻡ ﺖﻤﺗ ءاﻮﺳ ( ﺮﻬﺷﻷا لﻼﺧ ـﻟا ٢٤ ؟ةﺮﻴﺧﻷا
Yes ﻢﻌﻥ No ﻻ ةﺮﻘﻓ ﺲﻤﺨﻟا ﻢﺴﻘﻟا ﺔﺌﺒﻌﺗ ءﺎﺝﺮﻟا ﻢﻌﻨﺑ ﻚﺘﺑﺎﺝإ ﺖﻥﺎآ اذإ ) ت (

b) Have you or any person you wish to insure consulted with a specialist, been admitted to a hospital, nursing home or any other medical
facility or been advised to have any medical examinations or investigations during the last five years? If “Yes” complete details in 5
(c)

ب) ﺳو يأ وأ ﺾﻳﺮﻤﺘﻟا ﺖﻴﺑ وأ ﻰﻔﺸﺘﺴﻤﻟا ﻰﻟإ لﻮﺧﺪﻟا صﻮﺼﺨﺑ ﻲﺋﺎﺼﺧأ وأ رﺎﺸﺘﺴﻡ ﻦﻡ ﺔﻴﺒﻃ ةرﺎﺸﺘﺳا ﺔﻳأ جذﻮﻤﻨﻟا اﺬه ﻲﻓ ﻪﻤﺳا جرﺪﻡ ﺮﺧﺁ ﺺﺨﺷ يأ وأ ﺖﻥأ ﺖﻴﻘﻠﺗ ﻞه ﺔﻠﻴ
؟ةﺮﻴﺧﻷا ﺲﻤﺨﻟا تاﻮﻨﺴﻟا لﻼﺧ ﺔﻴﺒﻃ تﺎﺹﻮﺤﻓ ﻞﻤﻌﺑ ﺎﺡﻮﺼﻨﻡ ﺖﻨآ وأ ىﺮﺧأ ﺔﻴﺒﻃ
Yes ﻢﻌﻥ No ﻻ ةﺮﻘﻓ ﺲﻤﺨﻟا ﻢﺴﻘﻟا ﺔﺌﺒﻌﺗ ءﺎﺝﺮﻟا ﻢﻌﻨﺑ ﻚﺘﺑﺎﺝإ ﺖﻥﺎآ اذإ ) ت )

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1
Mahmoud S. Shalab
Medical Underwriting

c) Have you or any person(s) you wish to insure ever suffered from any following. Please answer “Yes” or “NO” to all questions written
below:
ت) ﻞﻔﺳﻷا لوﺪﺠﻟا ﻲﻓ جرﺪﻡ ضﺮﻡ يأ ﻦﻡ جذﻮﻤﻨﻟا اﺬه ﻲﻓ ﻪﻤﺳا جرﺪﻡ ﺮﺧﺁ ﺺﺨﺷ يأ وأ ﺖﻥأ ﺖﻴﻥﺎﻋ ﻞه . ـﺑ ﺐﺝأ " ﻢﻌﻥ " وأ " ﻻ " ﺔﻘﺡﻼﻟا ﺔﻠﺌﺳﻷا ﻊﻴﻤﺝ ﻰﻠﻋ .

No.
ﻻ
Yes
ﻢﻌﻥ

1. ﺮﻡأ ،ﻂﻐﻀﻟاو ﺔﻳﻮﻡﺪﻟا ﺔﻴﻋوﻷا و ﺐﻠﻘﻟا ضا
ﺔﺧوﺪﻟا.
1. Heart ,Blood vessel, Hypertension and circulatory
diseases
2. ﺔﻴﺙاروو ﺔﻴﻘﻠﺧ تﺎهﻮﺸﺗ ضاﺮﻡأ 2. Congenital and hereditary diseases
3. مﺪﻟا ضاﺮﻡأ ،نﺎﻃﺮﺴﻟا 3. Cancer, and blood diseases
4. ﺔﻴﺴﻔﻨﻟاو ﺔﻴﻠﻘﻌﻟا ،ﺔﻴﺒﺼﻌﻟا ضاﺮﻡﻷا 4. Neurological, mental and psychological disease
5. ﺔﻳﻮﻠﻜﻟا تاﻮﺼﺤﻟا و ﻰﻠﻜﻟا ضاﺮﻡأ 5. Kidney and calculus disease
6. ﻲﻤﻀﻬﻟا زﺎﻬﺠﻟا ضاﺮﻡأ 6. Digestive disorders
7. ﻲﺴﻔﻨﺘﻟا زﺎﻬﺠﻟا ضاﺮﻡأ 7. Respiratory system diseases
8. ﻪﻌﺑاﻮﺗو ﺪﻠﺠﻟا ضﺮﻡأ 8. Skin and subcutaneous tissue diseases
9. زﺪﻳﻹا 9. AIDS
10. تﻼﻀﻌﻟا و مﺎﻈﻌﻟا ضاﺮﻡأ 10. Bone and muscle diseases
11. ﻲﻠﺳﺎﻨﺘﻟا و ﻲﻟﻮﺒﻟا زﺎﻬﺠﻟا ضاﺮﻡأ 11. Genitourinary system disorders
12. يوﺎﻔﻤﻴﻠﻟا زﺎﻬﺠﻟا ضاﺮﻡأ 12. Lymphatic system diseases
13. ﻞﻡﺎﺡ ﺔﺝوﺰﻟا ﻞه 13. Your wife pregnant
14. ضاﺮﻡأ ﻞﺜﻡ ﺔﻴﺑﻼﻘﺘﺴﻟاو ءﺎﻤﺼﻟا دﺪﻐﻟا
ﻜﺴﻟا يﺮ
14. Endocrine and metabolic disorders like diabetes
15. ﺔﻋﺎﻨﻤﻟاو مﺰﺗﺎﻡوﺮﻟا 15. Rheumatoid and immunology
16. ﺔﻘﺑﺎﺴﻟا ﺔﻴﺒﻄﻟا تاءاﺮﺝﻹاو تﺎﻴﻠﻤﻌﻟا 16. Pre-operative and operation
17. ﺮﻬﻈﻟا مﻻﺁ 17. Back Pain
18. ﻲﺒﺼﻌﻟا زﺎﻬﺠﻟا ضﺮﻡأ 18. Nervous system diseases
19. ﻦﻴﻌﻟا ضاﺮﻡأ نذﻷاو 19. Eye and Ear diseases
20. ﺮﻴﻏ ضاﺮﻡأ ، ﺔﻴﺽﺮﻡ ىﻮﻜﺷ ،لﻼﺘﻋا يإ
ﻩﻼﻋأ ةرﻮآﺬﻡ
20. Any sickness, medical complication, any condition not
listed above

If answer is “Yes” to any of the above question, please give the full details below.
ﺔﺑﺎﺝﻹا ﺖﻥﺎآ اذإ ) ﻌﻥ ﻢ ( ﻰﻥدﻷا ﻢﺴﻘﻟا ﻲﻓ ﻞﻴﺹﺎﻔﺘﻟا ﺮآذا ﺔﻘﺑﺎﺴﻟا ﺔﻠﺌﺳﻷا ىﺪﺡإ ﻰﻠﻋ .

Pre-existing Medical Conditions & Previous Operation
ﺔﻘﺏﺎﺴﻟا تﺎﻴﻠﻤﻌﻟاو ﺔﻨﻣﺰﻤﻟا ضاﺮﻣﻷا
No.
ﻢﻗﺮﻟا
Insured Name
ﻊﻔﺘﻨﻤﻟا ﻢﺳا
Diseases Details
ضﺮﻤﻟا ﻞﻴﺹﺎﻔﺗ
Date of diagnosis/treatment/operation
ﺦﻳرﺎﺗ ضاﺮﻋﻷا ﺺﻴﺨﺸﺗ / جﻼﻌﻟا / ﺔﻴﻠﻤﻌﻟا
Please enclose relevant medical reports
ﺔﻡزﻼﻟا ﺔﻴﺒﻄﻟا ﺮﻳﺮﻘﺘﻟا قﺎﻓرإ ءﺎﺝﺮﻟا
Name of the Hospital/
Attending
Physician.
ﻰﻔﺸﺘﺴﻤﻟا ﻢﺳا/ ﺞﻟﺎﻌﻤﻟا ﺐﻴﺒﻄﻟا
1.
2.
3.
4.

Current Medications
ﻬﻟوﺎﻨﺘﺕ ﻲﺘﻟا ﺔیودﻷا ﺎﻴﻟﺎﺣ ﺎ
No.
ﻢﻗﺮﻟا
Insured Name
ﻊﻔﺘﻨﻤﻟا ﻢﺳا
Medicine Name
ءاوﺪﻟا ﻢﺳا
Daily Dosage
ﺔﻴﻡﻮﻴﻟا ﺔﻋﺮﺠﻟا
Date from which medicines were started
ءاوﺪﻟا لﺎﻤﻌﺘﺳا ﺔﻳاﺪﺑ ﺦﻳرﺎﺗ
1.
2.
3.
4.
5.

d) Has any member of your family (parents, brothers or sisters) had heart disease, high blood pressure, diabetes, congenital disease or
deformity, cancer, nervous or mental disorders, kidney disease, hemophilia and/or muscular dystrophy?
ح) ﻚﺘﻠﺋﺎﻋ ﻦﻡ ﺺﺨﺷ يأ وأ ﺖﻥأ ﺖﻴﻥﺎﻋ ﻞه ) تاﻮﺧأ وأ ةﻮﺧأ ،ﻦﻳﺪﻟاو ( ﻷا ﻦﻡ ﺔﻴﻟﺎﺘﻟا ضاﺮﻡ ) ،نﺎﻃﺮﺳ ،ﺔﻴﻘﻠﺨﻟا ضاﺮﻡﻷا وأ تﺎهﻮﺸﺘﻟا ،يﺮﻜﺳ ضﺮﻡ ،مد ﻂﻐﺽ ،ﺐﻠﻘﻟا
ﺔﻴﺒﺼﻋ ضاﺮﻡأ / ﺔﻴﻠﻘﻋ / رﻮﻋﺎﻨﻟا ، ﺔﻳﻮﻠآ ضﺮﻡ ،ﺔﻴﺴﻔﻥ ) ﻦﻡﺎﺜﻟا ﻞﻡﺎﻌﻟا ﺺﻘﻥ ( ؟ﺔﻴﻠﻀﻌﻟا تاﺮﻤﻀﻟا ،
Yes ﻢﻌﻥ No ﻻ

If you have answered YES, please give the following information: اذإ ﺔﻴﻟﺎﺘﻟا تﺎﻣﻮﻠﻌﻤﻟا ءﺎﻄﻋإ ءﺎﺝﺮﻟا ﻢﻌﻨﺏ ﻚﺘﺏﺎﺝإ ﺖﻥﺎآ :
Name of person(s)
ﺺﺨﺸﻟا ﻢﺳا ) صﺎﺨﺷﻷا )
Medical condition(s)
ﺔﻴﺒﻄﻟا تﻻﺎﺤﻟا ﻞﻴﺹﺎﻔﺗ

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Mahmoud S. Shalab
Medical Underwriting

6. Life Style 6. ةﺎﻴﺤﻟا بﻮﻠﺱأ

a) Do you or any person(s) you wish to insure is a professional sportsman or engage in any hazardous sports or activities?
أ) يأ وأ ﺖﻥأ ﻞه ؟ةﺮﻄﺧ تﺎﻃﺎﺸﻥ وأ تﺎﺽﺎﻳر ﺔﻳأ ﻲﻓ كرﺎﺸﻳ وأ فﺮﺘﺤﻡ ﻲﺽﺎﻳر ﻚﺘﻠﺋﺎﻋ ﻦﻡ ﺺﺨﺷ
Yes ﻢﻌﻥ No ﻻ

If you have answered YES, please give details of your activities: ﺎﻨه ﻞﻴﺻﺎﻔﺘﻟا ﻂﻋأ ﻢﻌﻨﺏ ﺖﺒﺝأ اذإ


b) Do you or any person(s) you wish to insure: ب) ؟ﻪﻟ ﻊﺑﺎﺗ ﺺﺨﺷ يأ وأ ﻪﻟ ﻦﻡﺆﻤﻟا نﺎآ نإ ءاﻮﺳ ﻲﻟﺎﺘﻟا ﺔﺌﺒﻌﺗ ءﺎﺝﺮﻟا

Smoke ﻦﻴﻨﺧﺪﻡ Yes No
Drink Alcohol لﻮﺤﻜﻟا بﺮﺸﻳ Yes No
Stay abroad for more than 60 days during the year ﻦﻡ ﺮﺜآأ ﺔﻟوﺪﻟا جرﺎﺧ ﺲﻠﺠﻳ ٦٠ ﺎﻡﻮﻳ Yes No

If you have answered YES, please give details of quantity and frequency:
ﺔﻴﻟﺎﺘﻟا ﻞﻴﺻﺎﻔﺘﻟا ءﺎﻄﻋإ ءﺎﺝﺮﻟا ﻢﻌﻨﺏ ﺔﻘﺏﺎﺴﻟا ﺔﻠﺌﺱﻷا ىﺪﺣإ ﻰﻠﻋ ﻚﺘﺏﺎﺝإ ﺖﻥﺎآ اذإ :


7. Insurance History 7. ﺔﻴﻨﻴﻣﺄﺘﻟا ةﺎﻴﺤﻟا ﻦﻋ ﻞﻴﺻﺎﻔﺕ

a) Are you presently insured under any other health insurance coverage?
؟ﺮﺧﺁ ﻲﺤﺹ ﻦﻴﻡﺄﺗ ﺔﻳأ جذﻮﻤﻨﻟا اﺬه ﻲﻓ ﻢهؤﺎﻤﺳأ ﻦﻳرﻮآﺬﻤﻟا ﻦﻡ ﺺﺨﺷ يأ وأ ﺖﻥأ ﻚﻳﺪﻟ ﻞه

Yes No
b) Are you currently making or do you intend to make any life, accident, critical illness or health Insurance proposals to
any other insurance company?
ﻚﻳﺪﻟ ﻞه ﻦﻴﻡﺄﺗ ﺔآﺮﺷ يأ ﻊﻡ ﻲﺤﺹ ﻦﻴﻡﺄﺗ وأ ﻦﻡﺰﻡ ضﺮﻤﻟ وأ ثداﻮﺤﻟا ﺪﺽ وأ ةﺎﻴﺤﻟا ﻰﻠﻋ ﻦﻴﻡﺄﺗ ﺔﻳأ ﻚﻳﺪﻟ نﻮﻜﻳ نأ ﺮﺽﺎﺤﻟا ﺖﻗﻮﻟا ﻲﻓ يﻮﻨﺗ وأ ﺎﻴﻟﺎﺡ
؟ ﺧأ

Yes No

c) Has any of your application for life, accident, critical illness or health insurance been declined, Postponed or accepted on
special terms? ؟ﺔﻴﺋﺎﻨﺜﺘﺳا طوﺮﺸﺑ ﻞﺒ ﻗ وأ ﻞﺒﻗ ﻦﻡ ﺾﻓر ﻲﺤﺹ ﻦﻴﻡﺄﺘﻟا وأ ثداﻮﺤﻟا ﺪﺽ وأ ةﺎﻴﺤﻟا ﻰﻠﻋ ﻦﻴﻡﺄﺘﻠﻟ ﺐﻠﻃ يأ ﻚﻳﺪﻟ ﺪﺝﻮﻳ ﻞه

Yes No
d) Has a company terminated or refused to renew your contract of life, accident, critical illness or health insurance? كﺎﻨه ﻞه
؟ﻲﺤﺹ ﻦﻴﻡﺄﺗ وأ ﻦﻡﺰﻡ ضﺮﻤﻟ وأ ثداﻮﺤﻟا ﺪﺽ وأ ةﺎﻴﺤﻟا ﻰﻠﻋ ﻚﻟ ﻦﻴﻡﺄﺗ ﺔﻳأ ﺖﻐﻟأ وأ ﻚﻨﻴﻡﺄﺗ دﺪﺠﺗ نأ ﺖﻀﻓر ﺔآﺮﺷ ﺔﻳأ

Yes No

If you have answered YES to any of the above questions, please give the following information:
ﺔﻴﻟﺎﺘﻟا ﻞﻴﺻﺎﻔﺘﻟا ءﺎﻄﻋإ ءﺎﺝﺮﻟا ﻢﻌﻨﺏ ﺔﻘﺏﺎﺴﻟا ﺔﻠﺌﺱﻷا ىﺪﺣإ ﻰﻠﻋ ﻚﺘﺏﺎﺝإ ﺖﻥﺎآ اذإ:
Name of the Company
ﺔآﺮﺸﻟا ﻢﺱا
Insurance Type
ﻦﻴﻣﺄﺘﻟا عﻮﻥ
Coverage
ءﺎﻄﻐﻟا
Sum Insured / Limit
ﻦﻴﻣﺄﺘﻟا ﻎﻠﺒﻣ / ﻰﺼﻗﻷا ﺪﺤﻟا
Year
ﺴﻟا ﺔﻨ




8. Declaration 8. راﺮﻗإ

- I hereby declare that to the best of my knowledge and belief the above particulars are true and complete and full information has been disclosed. I understand that
non-disclosure or misrepresentation of any fact may lead to the refusal of any claim or the cancellation of any policy.
- أ ءﺎﻄﻋإ ﺔﻟﺎﺡ ﻲﻓ ﻪﻥﺄﺑ ﻲﻠﻤﻌﺑ ﺮﻗأ ﺎﻤآ ﺔﻡﻮﻠﻌﻡ ﺔﻳأ ءﺎﻔﺧإ ﻢﺘﻳ ﻢﻟو ﺔﻠﻡﺎآ و ﺔﻘﻴﻘﺡ ﺎﻬﻠآ ﻩﻼﻋأ ﺎﻬﺑ ﺖﺡﺮﺹ ﻲﺘﻟا تﺎﻡﻮﻠﻌﻤﻟا ﻞآ نﺄﺑ يدﺎﻘﺘﻋأو ﻲﻠﻤﻋ ﻦﺴﺡﺄﺑ ﻪﻥأ ﺎﻨه حﺮﺹأ وأ ﺔﺌﻃﺎﺧ تﺎﻡﻮﻠﻌﻡ ﺔﻳ
ﺔﺼﻴﻟﻮﺒﻟا ءﺎﻐﻟإ ﻰﺘﺡ و ﻲﻠﺒﻗ ﻦﻡ ﺔﻡﺪﻘﻡ ﺔﺒﻟﺎﻄﻡ ﺔﻳأ ﺾﻓر ﻰﻟإ يدﺆﻴﺳ اﺬه نﺈﻓ ﻖﺋﺎﻘﺡ ﺔﻳأ ءﺎﻔﺧإ ﺔﻳأ .
- I hereby authorize the giving of (a) medical information from my doctor and any doctor who has at any time attended me and (b) information from any life /
health assurance office to which a proposal on my life has at any time been made.
- ﻲﺑ ﺔﺹﺎﺨﻟا ﺔﻴﺒﻄﻟا تﺎﻡﻮﻠﻌﻤﻟا ءﺎﻄﻋﺈﺑ ةﺎﻴﺤﻟا ﻰﻠﻋ ﻦﻴﻡﺄﺗ وأ ﻲﺤﺹ ﻦﻴﻡﺄﺗ ﺔآﺮﺷ يأ وأ ،ﻲﺼﺤﻔﺑ مﻮﻘﻳ ﺮﺧﺁ ﺐﻴﺒﻃ يأ وأ صﺎﺨﻟا ﻲﺒﻴﺒﻃ ﺎﻨه ضﻮﻓأ ﻲﻨﻥإ ﺎﻤآ.
- I hereby agree that this proposal and declaration or any written statement made by me in reference to the proposal shall be the basis of the contract between the
Company and me.
- ﺳﻷا ﻮه نﻮﻜﻴﺳ ﺐﻠﻄﻟا عﻮﺽﻮﻤﺑ ﺔﻗﻼﻋ ﻪﻟ ﻲﻠﺒﻗ ﻦﻡ رﺮﺤﻡ ﺮﺧﺁ راﺮﻗإ يأ وأ راﺮﻗﻹا اﺬه نﺄﺑ ﺎﻀﻳأ ﻖﻓاوأ ﻲﻨﻥأ ﺎﻤآ ﻢﻜﺘآﺮﺷ ﻦﻴﺑو ﻲﻨﻴﺑ ﺪﻗﺎﻌﺘﻟا ﻲﻓ سﺎ .

Applicant’s Signature: Date:
ﺦﻳرﺎﺘﻟا ﻦﻴﻡﺄﺘﻟا ﺐﻟﺎﻃ ﻊﻴﻗﻮﺗ











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