health

International Protection Document

Type of transaction:*

Number of individuals involved:

Subscriber data

Civil ID No*

Nationality*

First name in English *

Last name in English *

Full Name in Arabic *

Family name in Arabic*

Date of Birth *

Marital status*

Address*

E-mail*

Gender*:

Contact number*

Specialization*:

Occupation*:

Document data

Effective date of the document*:

Beneficiary data

Civil ID number	First name in English	English last name	Reltionship	minor

Details of health status

Are you in good health?
Have you ever complained of any disease?
Have you ever been involved in an accident, injury or any operation?
Have you received or are currently taking any treatment for any disease?
Do you have alcohol or any drugs?
Do you smoke cigarettes or tobacco?

I acknowledge that the data and answers in this form are correct and complete to the best of my knowledge and belief and agree that this statement along with any statement besides the medical examination should be the basis of the contract between me and the company. If any incorrect statement is made in it, or if there is any material concealment, the insurance contract will be null and void and all amounts paid in this respect shall be confiscated by the company. I fully understand that the company will not be at risk for my life until issuing an official letter of acceptance by the company and paying the premium owed to me by.

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Subscriber data

Document data

Beneficiary data

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