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PAK-QATAR FAMILY TAKAFUL LIMITED Health Declaration Questionnaire PAK-QATAR FAMILY TAKAFUL Together for Better OatiypL guste, Enpioer os ‘Con Person Atle) Desipaion employee) Reon thet tenn gi Nave of opse Pecint Taber Nien rds Nae ae trseser aac WG | hee # rae Genter Flee Puke | Paatsann SPE me ym Oe [CPTI ETT rrr) oasaee | Bact Daiy Date VES nSiin | poe (1) Ca ET) 2% | Cotsen LI CA CTT Ta Srorse Aasthonn§a! a ae = yee DapweniGace pn | Prat es cons iow 1 Hana pnt re a see at) ban WSibpratannbiry barbed Labels 4 incibinnoncveramcdonipecsems Tiseopeae yor, NOL Le voip au feadibipreheah 2 Derehu nena aren pps tes ve Oy wo? reeled Pie Briain SEE ne ‘Rane Oa we Cee iilincsted + oan 7 vee oh Depa ; L 1 een Yes " Peon a woe twee “OY OF ae aehs Provide details for any "YES" answers on next page. 1s you ay ren rae ore yuo | teen Vested bv aheatewe pride Ean; mon the pas heyear? YS JU 7 TEP wnponcecvom umes RUE » Cake Cece Dutweslap okarlorNepusRepruoe eee veDJ4 sole SHS hb Tr Binbtabuh inh de tenn Dearie Sravme QUAD ancien DL batineh AMR ASMipSiee bibs tinea deat oon ancrsade > Gaitcengtenaseniweyatencaciocee ves J Nee raoyeDbTe nSensfgif © formore thn 3oconea= Ga Tent BELL RAISE mC b oH 1 oe ei nt eet a at vel) Nel? Mme btu Lon [§ Geievecumpteayopenonerettoncceiormoitng vee Jy Nel je teleesMintonbinbiiitewiMiGig (For eres one regan ort yo eh ny Yet Ne ead Atllnbilans Eira EEAY 9 Prnecolopal seca or bet dese / adel condo? an Road Trae Accident pane ‘ary, 2001 2001-7 13 Days Hospal Cee die Pron Dr. Saleem, AKUH, Karachi GA densugorer Ay Declaration by the Empl eee x ‘ery cert tht al anes to questions appearing on tis fom are tue and complet othe best fry snowide and bee. For Underingand di proces pve my permissonto:Aryphscan or other tadtal pcrtche: hasta cine oer muds or adalat ay ata ‘Tesurance company, or employer to ge Pear Farka Lmtd os ‘ators reprezetate ALL INFORMATION any bea inci epi recor th elerence oa Scines accel aby eaters carnation vel Fam tel [lesion advisor hosptleaton anderen hereby apy for he Fl Coseage dere ter sd concsone of heater Paricpart [Document meas the ba oo aage Corban ely shal py the canration mentored abow to heparin dacontrston ‘rahi rnnas ny all cove uta in case weve te bas of fonrngetsNon-cortnoior,leertj and naw ht he diconnuanc fad Srrrtonon ye paracpart on my anata Company wil tmnt my Famiy Tat cover aera. Dite of tataent sera el oiiiseotnL over thu lL Retr tet Wb halen MOSSEL E wl Ai Bitt HER meres erie KAP oli PiSicd de bundairsiesiel Aah ta tela 2 PHEN CPLA ELIS Ai Pein een Geib te SEAS cg ert EW SORE wb PSO CIB A SoH POL plant YRS AR LI GSP Srgsinchipd tenis SERS Sorbie Sesecinn pa Seibvien SAS IOLP hey eK ene aie IA Sa DAT Po IOP se Fire oS But ober Peaster er on OE ele aPeacinssee PLP le cerfirn tat the information rovide sue strut thabest furore bale an recor Wie agree to the Parteparts Group Taal fe benefits fo the eigble prespects weer lise Partgpants Membership Docrnert Ne ‘rsd tht sch benefits are parable subject to and in aecorsnce withthe ems he terre of Master Paricpare Nemeerhp Oncuman here apleab. ra to dct the rece carton from te eurngo the ei We {hid Ths agreement al cease to operte in espect any person Tider the seve and forward them prot to Pak ata Far i Taatl i helshe ‘causes to be Rembertenployen ofthe carsgaup covrea under the Parepart Membership Document he eate of su cecontsuance or on sich exer Chie as aged wan the person concern In efter case, We undertake 10 rot ‘the company accor Date of Statement aa (iE pentrr Ebi SAI SBE SINE SiC oA SAP A terior BlTOLPES ELAS ype Peuaer AEDS OGL AL ok OsI-O MAG ALA La 0 UIT online) Neate? SELLS Lut TER SMa pie wwii Lcbins fitch SN gibt A TO ale ieei SoS Pre ie bit ile todel fara trd LAST WL wip haut ke SNA ZIONS ee weber ase eae hopin Ses based Expyers Sipsture PLO Che o a oO ck List (to ensure timely process) Valid Computerised Naor! erty Card Copy of past weatment record ay Copies oft sc months ab tsi able For Offce use only Recevng cate Decison Undenveting dite:

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