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HDF Health Declaration Form (May-2016) - 2 PDF
HDF Health Declaration Form (May-2016) - 2 PDF
Important Note: Kindly disclose complete medical history in this form. Please note that if the pre-existing medical condition is NOT DISCLOSED, we may decline
the claim relating to it. If the medical condition is disclosed, we may / may not cover that medical condition subject to the terms and conditions of this
policy.
Pre-existing medical conditions are diseases, Illness or injuries of a person against which he/she receives treatment, incurs expenses, receives diagnosis from a
doctor (even if no treatment is provided) or was of at anytime prior to applying for insurance.
Client's Name:
Employee/ Dependent's Name:
Designation/ Employment Joining Date:
Employee Code/ Marital Status/ Blood Group:
C.N.I.C #/ Mobile #:
Residential Address:
Family Details: Please write Family members (spouse, son, daughter) to be covered. Attach additional form, if necessary
Insurance
S. No. Name in CAPITAL letters Relationship Sex (M/F) Birth date Height & Weight Marital status Marriage date
Effective Date
1 Self
2
3
4
5
6
If you have answered Yes to any of the questions 1-9 above, please provide details i.e. name of the person, nature/ duration of illness, name of
attending physician/ hospital, type of treatment and whether any further tests/treatment/ suggested/required. Attach additional sheets if necessary
and also attach photocopies of the relevant medical reports & or prescription of medicine.
Declaration: I hereby certify that I have filled the above information to the best of my knowledge and belief.
Plan A B C D E
With this form please attach (Where applicable)
1) CNIC Copy of all adult eligible family members insured under this policy.
2) Copy of Marriage deed.
3) NADRA's birth certificate for kids under 18.
4) For Dependent's addition, copy of employee's insurance card
________________________________ ________________________________
Signature of Employee Name, Designation & Signature of Client's authorized officer
for self and on behalf of his/her dependent Dated with official seal Dated
Head Office: Lakson Square, Building No. 3, 11th Floor, Sarwar Shaheed Road, Karachi-74200, Pakistan. Phones: 92-2135657445-9 Fax: 92-21-35671665