7/28/2019 Ammar Lateef Oman Insurance Filled Application

1/3

Oman Insurance Company (P.s.c.) .f "(.t~tY ~.J l-.J~ ~~,/ ,/

PROPOSAL FORMINDIVIDUAL MEDICAL INSURANCE

Please complete this form using BLOCK CAPITALS and by ticking the relevant items. Kindly enclose Passport copies and photographs ofthe members to be insured.! 1. Applicant's Details ~;;J I ..,.J 1..b ' :: 'L . o . , J a . . .1 I

- ,- - A t Y l f Y 1 A I Z . . - - - - - - 4 E g J Z E _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ Date of Birth : dd JlL mm'-_k J Y _ _L 9 - & r -t"''il - .. ( e .l~1 t:'-,w' S ! i . " ~ . Occupation :. /; l ! f ! : : . c g Y J k e d ~00 _ _ I _ Y . ' L l } ! ! , . o / Nationalrty : p.~'_~- A . T A -N . l _4-J 1 tJ ~I fl80l Weight (kg) r&7tlL-.l (~)j)1 L-.l

No. of,Children D UAE Residents Only.l'iJ 'iI.l.lc. ..bi!wI.)L.)'1J y J ;..b~Name

Gender B.Marital Status

~~iijJWI Bale.fi; Female~ Height (em)(ru) J "lJ 1Darriedr;:J y.. Singleyjci Divorced~/~D. Dependents' Details. ~ ...,..~~J .!..>U:i2rName of Dependeni- J h.J 1~ t"'1I1------ 1

. Relationship to ApplicantI 0:"~..,..JU,;~''''1

Weight (kg) Iuj)1

Date of Birth ..L J l;..J 1t:'~.wDay fY. Month~ year:u...Height (em)J "lJ 1

Ir - - - - - - - - . . - - - - - - - ,r - - - - = - - - - - - - - - - - - - - - - - - - - - - - - I I IE ~~=~--~-- - -~I f ~~l... I r-j

---~-1

I 3. Address u1fo.l\_3co~~~ame: .- -- P -f~X f-Q -J?1 .. t! :---------------- -- --- -----p~ : ~x: ~ E~~~~: .. -----------------~ ~~~-I--~--------------~ ~ I e ~ ~ ~~----------------------------- R e J i w i 1 - - ? ? - ': r . r r - 1 J - ~ 1 _ - < f - - - - - - Fax;S\i-----------------------------------------------I 4. (a) Geographical Coverage Required ~ ,:,."u...J I4!I.P.J 1UI.l.J I (I) .4DUAB o nly r-J UAB, occ & In dia n Sub-Continent.J .;;Uy...)'1 ~ WIi}ilI

7/28/2019 Ammar Lateef Oman Insurance Filled Application

2/3

a) Do you or any person(s) you wish to insure is a professional sportsman or engage in any hazardous sports or activities?d !>y.,.;. ~u,Ltl .,1~t....,t,u~I ~

(I

Oman Insurance Company (P.S.C.) . ~ /(. > ) ".h f/.1.,.~ ..t.(".0'l ~u-.->G.;,y v-=.-~" "

6.Life Style .\.;.oJI"t..j .6

lfyou have answered YES, please give details of your activities: U. J ;..oIJ :ilIJ . .>j ~ ~ IJ !

Smoke~Drink Alcohol J ~ yfoStay abroad for more than 60 days during the year L.J! 60 0" fol ~ .,.>11:;:..Jli.~

!.u~,,"~,,1 "l.u0-yJl utsu!1Y"'';I:ilI~~~1 (..,. . Yes ~NOYes NoYes Nob) Do you or any person(s) you wish to insure:

If you have answered YES, please give details of quantity and frequency::4til1 J .!...oIJ :ilIu, . , ! ~~,Jl1~ ~ ~'JI < 5 '" " " J .; ~~! u , ' U lj!

7.1.lIsura:nce History ~UJI .\.;.oJ \(:PJ ;..oI.i:i .7

a) Are you presently insured under any other health insurance coverage?!..foi ~ u,;. -I:i~I

7/28/2019 Ammar Lateef Oman Insurance Filled Application

3/3

2 Malnnoud S. ShalabMedical Underwriting

Oman Insurance Company (P.S.C.) s- J /'(- 11. (/J__ c_. t ("' lY' ~\....lJ~1.......Y v . . . . = - - v - ' " "/. /-

c) Have you or any person(s) you wish to insure ever suffered from any following. Please answer "Yes" or "NO" to all questions writtenbelow:

.~IJ I Uw,\11~ ~ "'J" J I "~" -!~i _J i..\1rJ J~.) i . J " " ' , y . y . ",1o- io~I:"';.) "--'I E . J " '" y:l ~ ',?1J IWlI~.C J .h(.::.Yes No_~ 'J1. Heart ,Blood vessel, Hypertension and circulatory V ,y.\yl ..b...;,J IJ A.;y>lL~:l\J yliIl .1diseases .:G.yl\2. Congenital and hereditary diseases ./ ~.J J J 4 f o ;. . wlA~ ,y.\yi .2

3. Cancer, and blood d.iseases v ~ ,y.lyi '0U,yJ I .34. Neurological, mental and psychological disease -: ~J~ ,'.))_",.)1 ~y'1l .45. Kidney and calculus disease v A . ; ) $ . l \ w\y-=l J ~ ,y.\yi -56. Digestive disorders V' ~ j~1 ,y.\yi .67. Respiratory system diseases VA ~ j~1 ,y.lyl _ 78. Skin and subcutaneous tissue diseases .~~ A.s..;IYJ ;4.lI,y.yi .89. AIDS ~ ~11 _9lD . Boneand.muscle diseases - ../ W)W,.j1J ~.kll ,y.lyi .lD11. Genitourinary system disorders v ~li:il\ J ~~ j~1 ,y.\yoi .1112. I..vmphatic system diseases ../ "'J 1i.)J 1j~,y.IY'i ,J213. Your wife pregnant V J ,.6.4)I J A .13]4. Endocrine and metabolic disorders like diabetes V elk ~J .I......J \ J ..li.lly.lyl .14',?fi..J \15. Rheumatoid and irurnunology V ~WIHy1...-,jl _1516. Pre-operative and operation V ~.J1 ~ wl.Iy..'1IJ wt,.l-l\ .16I?Ba.ckPain ,/ ~1~11 _ 1 718. Nervous system diseases ,/ ~j~,y.yi .1819 , Eye and Ear diseases i/ (j.YIJ ~ ,y.lyl .1920_ Any sickness, medical complication. , any condition not ../ .J !f:. ulolyi ,A.;...;.y :I 1

-No. Insured Name Medicine Name Daily Dosage Date from which medicines wererAjl ~1i'""'1 .IJ .>1'""'\ A.;..~\:i.:.~1 started.IJ .>It,...:;...1.;1.l.): : : ; . J i : JL2.3.4. -5.

Current MedicationsWI.: .. \ f J j t Z : i u = > l1 ~J~I

d) Has any member of your family (patents, brothersor sisters) had heart disease, high blood pressure, diabetes, congenital disease ordeformity, cancer, nervous or mental disorders, kidney disease, hemophil ia and/or muscular dystrophy?

,y.lyl ,ui..6y>A.;ihil