Bupa A urb al_a_4] aig__oi Medical Declaration Form PU RSs aut adctin [] 5) fnew [Jan New conan Dali BAO 2 ag amet Caeast 52 tin ant CRN $80 SE NOA sisi ssats recente | Awana ee [eee ee ares —_ARSAIAT SE S20 SANS iL MustT Ag aS aaT a ne Yer/oal : i ou elo | Sasi SIU ssa nstae | 2 bo youve cro iene ed Sein Tye Ve cy sm ra oye ant alse Untmaytecisioes Trea concer recs |B | | ee tN te Gio Neda Aone ores er line ae? il eer 5. Do you have congenital dsorders or hero (Gissaces tat afoct te inavidual during fet! Hf or tlseases resulting from ganetc dafect or dorder or tansmttea trom ane generlion to another? [seston tt cng ug aa yo cd ya oad ictal gulsue eaaaitg tay | waa 4. Do you have eye danass limited to: Cataract, Glaucoma, Corneal Disease 9 Retinal Diseare? 5 Do you have hone sisese imited to: Vertaal cc a Oh eas 994,98 99 Bh es prolapse Selon arthris or igoment tears? a Men 9 wed 6. Preanant Females only: L ‘Current sinale pregnant. | ‘Curent sinale pregnancy wth previous CS delivery | seu taaveaua ue | ‘Current mutipe pregnancy I Perret) Expected delivery date Saag ut Dependents Details pees [tere! | HosctaNarme _roatontio | Gander ae me Lae Se] ‘Wo attest that the insured employee personally fled-out this form ang signed Ion his/her own behalf and on behalf of hs/her aependents Hs Brower, we ile ald respon a tear oss ane syle Aya ye al gpa aig! Ss yopsaadn | Se Holl a BAS 0 oe Liab aD | “his declaration has been sued in both Arabic and Engle, I the event of AF Ascrepancy in the lterprtation of te a tant, the Arabic tat presale eit andl nce ee aan ee In ae of a "Yes" ansiner on any case aula nav egnusue ‘Undertaking: 1.1 hereby undertake thot oll above information i correct and the se Secoptance of my onvolment wil bo on the bars of sven inormation and | {that Supa Arabia for Cooperative surance has the right fo contact the td ad i a ig oe aalsobelonSia Ua 9. Sida hae gaa a ll Aya hay wilesasatil | hospital Ideal with to colect any medical information needed io assess | bousilal es s9 uD loge dilasglasa ts the sks. | 2. agree that Bups Arabia for Cooperative Insurance has the ight to psc lis al at yu al ld aa ay dle dar | ‘eject the covarogu/laims in ulin case of no declaration of any casets) | agin lta anh 8 gl otioh kate gue Brior tu the contractual dat or before enrolling ot sang a ew mame Suing tha coatroce 5. thereby confirm resding and understanding all ints presented in this ‘orm and agree that not marking any caze understood ae "Nothing ‘equies deciration’ and sign on these basi ioteiaiiawicatngor conte hid» | ah sual 9 9 ile | ntty Veataas | name: 2 SODA ssn Bint Soa x ‘ on