INDIVIDUAL AND FAMILY APPLICATION CHECKLIST (UAE)

How to Apply
Completing the application form should only take a few minutes.
Once completed, you can simply scan and email the copy to me together with
the following mandatory documents to process all on your behalf:

Required for all the members in the policy

Passport Copy
Visa Copy
Emirates ID copy (Front & Back)
Passport Sized Photo in JPEG format
Medical Reports (if applicable)

Please note that cards and policies cannot be activated until

the insurer received all the documents and payments.

I confirm that I have received and read the applicable Policy Wording.

I would like to receive information about (check all that are appropriate):

Critical Illness Cover Home Insurance Life Insurance General Insurance

Contact Us:
Dubai Office 110, The Offices, IBN Battuta Gate, Dubai, UAE, PO Box 391195 +971 (0) 4279 3800
Hong Kong Unit 1-11, 35th Floor, One Hung To Road, Hong Kong +852 3113 2112
Shanghai 21F, Crystal Century Plaza, 567 Weihai Road, Jing An District, Shanghai 20031, China +86 (0)21 6445 4592
Beijing Room 907, 8/F, Building 2, 1 Xidawang Road, Chaoyang District, Beijing 100020, China +86(0) 10 6464 0611
Singapore China Square Central, #14-05 18 Cross Street, Singapore 048423 +65 6536 6173
Bangkok 9th Floor (9D,E), President Tower, 973 Phloenchit Road, Lumpini, Pathumwan, Bangkok 10330 +66(0) 2 656 0180
Mexico Calle Lago Zurich 219 Piso 12, Miguel Hidalgo, Ampliación Granada, 11529 Ciudad de México +52 15528025929
All insurance mediation, advice and sales are conducted by Pacific Prime Insurance Brokers LLC. Regulated and licensed by the UAE Insurance Authority (license number 266)
and the Dubai Health Authority for the mediation of medical insurance. Registered office of Pacific Prime Insurance Brokers LLC is PO Box 391195, Dubai, UAE. Policies may be administered
by Pacific Prime Middle East DMCC which is owned and operated by Pacific Prime group of companies.

REF:2022-08
 Health Insurance
Application Form

Important Information
Kindly complete the questions on this form in BLOCK CAPITALS and tick the relevant boxes. It is important that you provide the following information
accurately so that we can process your application accordingly. This application must be completed in the Policy Holder or Insured Member’s own
handwriting (over 18 years old). If you need to make a correction, please highlight the change and add the date on it. For full details of the policy’s terms
and conditions, please refer to the table of benefits and membership handbook, available from GIG representative upon your request. We look forward to
welcoming you as a member of GIG Gulf.

You’ll be happy to know that GIG Gulf, previously AXA, is the most trusted insurance brand in the market and now number one across the region! Nothing
changes for our valuable customers. What you know and love about AXA will remain the same, including our people, products and quality.

*If you have any questions when completing this form, please contact your GIG sales team representative.

Important information about your membership declaration

• It is essential that you provide the complete information before you sign on your medical application form and your medical health declaration.
• This form must be received by GIG Gulf within (30 days) from the declaration date. If we receive this form after 30 days from the signed declaration
date, or with incomplete information, we will not be able to register your details and enrol you into the Health Insurance plan.
• It is advisable that you fill in your form with an up to date medical history before you sign and date this form.
• Claims will not be payable if you do not fully disclose any facts which could influence our assessment of this application and if you are in any doubt as
to whether any facts, you should disclose them.
• You are advised to keep a record of all information you disclose to us in connection with this application, including letters
• Medical information will be kept confidential. Personal data collected from you and your family will be used by GIG Gulf to process your claims,
administer your policy and may be used to detect and prevent fraud or improper claims. It will only be disclosed to those involved with your treatment
or care and, if applicable, to any person or organisation who may be responsible for meeting your treatment expenses.
• All membership documents and confirmation of how we deal with any claim you may make will be sent to the principal member.
• In the interest of continuously improving our service; your calls will be recorded and may be monitored.
• Prior to signing the application, please make sure that you have read, understood and agreed to the policy terms and conditions.

Policy holder details (please keep us informed of any change in your address)
First name: Middle name:

Last name: Gender: M F

Date of birth: DD/MM/YYYY P.O. Box:

Marital status: Single Married Divorced Widow

Address:

Email: Passport number:

Telephone number: Country Code Area code Number Mobile number: Country Code Area code Number

Occupation: Salary band: Not salaried >AED4k - AED12k pm >AED12k pm

Name of company (Employer): Nationality:

National ID number: Place of visa issuance:

VISA UID Number:

Existing or previous medical insurance

Do you have any health insurance currently in the G.C.C., or have previously received an Insurance quotation from GIG/AXA? Yes No

GIG/AXA Gulf Policy/quote number: Policy expiry date: DD/MM/YYYY

Other insurers Policy/quote number: Policy expiry date: DD/MM/YYYY

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 Your partner and family members (husband/wife & children to be insured with GIG)
Nationality/ Emirates ID Place of Visa
Title Name Relationship Sponsor Date of birth
passport number Number issuance
Wife/Husband/
DD/MM/YYYY
Son/Daughter
Wife/Husband/
DD/MM/YYYY
Son/Daughter
Wife/Husband/
DD/MM/YYYY
Son/Daughter
Wife/Husband/
DD/MM/YYYY
Son/Daughter
Wife/Husband/
DD/MM/YYYY
Son/Daughter

Confidential medical history

Declarations must be made in writing on this application. Verbal declarations are not acceptable. This section requests your health and medical history
details, past and present, including each family member named in the section above. Please tick Yes or No to every single question for every person
included in this application. If you tick Yes to a question, please provide full details in the following section. Please ensure you declare any known or
suspected condition, and any discomfort or symptoms experienced before your policy starts, even if professional advice has not yet been sought. Any
declared condition shall be covered under the pre-existing limit as per the plan terms and conditions.
Please note that GIG reserves the right to decline your claim and not pay it, if you do not provide us with full details of any existing medical condition.

Section A: Please answer all questions below and if any of them is answered with “yes”, provide details in section B:

Principal Dependant 1 Dependant 2 Dependant 3 Dependant 4 Dependant 5

Name

Height (cm)

Weight (kg)

Do you smoke? Yes No Yes No Yes No Yes No Yes No Yes No

1. Are you under any medical

supervision, undergoing any
medical/surgical treatment,
Yes No Yes No Yes No Yes No Yes No Yes No
was advised for the same or
have been admitted to the
hospital in the last five years?

2. Do you have any chronic

or pre-existing medical Yes No Yes No Yes No Yes No Yes No Yes No
condition*?

3. Are you taking any medication

or have been advised to take
Yes No Yes No Yes No Yes No Yes No Yes No
for a period more than seven
days?

4. Do you have any bone, joint or

Yes No Yes No Yes No Yes No Yes No Yes No
spine disease/complaints?

5. Have you been diagnosed,

investigated or treated for any Yes No Yes No Yes No Yes No Yes No Yes No
type of tumor, lump or cancer?

6. Do you have/had a medical

condition which is not listed in
the questions above (excluding
Yes No Yes No Yes No Yes No Yes No Yes No
cold or flu, vaccination, normal
checkups without medical
condition or symptoms).

7. For females only:

Yes No Yes No Yes No Yes No Yes No Yes No
a. Are you currently pregnant?

b. If you answered yes on the

above question, have you
Yes No Yes No Yes No Yes No Yes No Yes No
faced any complications up
to date?

c. Provide the date of your last

DD/MM/YYYY DD/MM/YYYY DD/MM/YYYY DD/MM/YYYY DD/MM/YYYY DD/MM/YYYY
menstrual period.

d. Are you currently trying to

get pregnant or undergoing
Yes No Yes No Yes No Yes No Yes No Yes No
any form of fertility
treatment?
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 Section B. Please provide details of all questions answered yes in the previous section:

*Chronic illness: a condition with one or more of the following criteria: last 3 months or more, leaves residual disability, is caused by non-reversible
pathological alteration, requires special training of the patient for rehabilitation, or may require long period of supervision or observation, e.g. diabetes
mellitus, hypertension, coronary artery disease etc.

*Pre-existing condition: an illness or health condition that was known and existed prior to submitting the application.

Your membership declaration

I hereby apply to be insured into the GIG Health Insurance program together with my family members listed above. I as the main applicant, confirm on
behalf of myself and proposed family members that the disclosed information given on this application form is complete, true and correct to the best of
our knowledge. I understand and acknowledge any pregnancy not declared at the time of this application’s coverage will be at the sole discretion of the
insurer. The insurer has the right to not cover any maternity claims to any undeclared pregnancy. I also acknowledge and understand any pregnancy,
which arises within forty calendar days from the date of this application; coverage will also be at the discretion of the insurer. I am the undersigned and
I confirm that I have received and read the terms and conditions of this policy, read and understood the table of benefits, list of exclusions and the full
terms and conditions of the opted for Health plan. I agree that GIG Gulf rules and internal guidelines would apply to me and to the eligible dependents
included in my membership.

I/We understand and agree that GIG reserves the right to request for medical examination and investigations report/s regardless of the declaration
provided to complete the enrollment process.

I/We confirm in case a complaint arises and coverage for the insured is denied due to any misrepresentation of facts stated in the application, it will be
the sole responsibility of me, the undersigned. I agree to indemnify and not hold GIG responsible for any denials, penalties and fines incurred due to
misrepresentation of facts.

I/We understand that any change on my plan benefits which upgrades or downgrades my Health Insurance plan would only be possible at the time of
renewal subject to GIG Gulf’s acceptance, the completion of a new application form in addition to any other forms or reports that may be requested by
GIG Gulf.

I/We formally request Gulf Insurance Group (Gulf) B.S.C. (c) (“GIG”) to collect, use, store, transfer and/or disclose any relevant information whether
within or outside of GCC (including sensitive health information and personal data) from any third party/partner in the due course of pricing and
servicing our insurance policy and thereby authorize them to disclose all such relevant information to GIG.

A photocopy of this authorization and all other related subsequent documents including communications in relation to this contract shall be considered
as effective and valid as the original.

We have been notified and agreed to the terms of GIG’s Data Use Statement which can be found at https://www.giggulf.ae/privacy.

GIG has taken steps to ensure that your information is held securely. You have the right to access your personal data held by GIG. If you believe that your
personal data held by GIG is inaccurate you have the right to ask for this to be rectified.

Signature: Date: DD/MM/YYYY

Gulf Insurance Group (Gulf) B.S.C. (c)

UAEEB07072022

Floor 39, Churchill Executive Tower, Business Bay

P.O. Box 5862, Dubai - United Arab Emirates
Telephone: +971 4 4476111
Email: info@gig-gulf.com, Website: www.giggulf.ae
Registered in the Insurance Companies Register - Certificate no. (69) dated 22/01/2002.
Subject to the provisions of Federal Law no. (6) of 2007 concerning the establishment of Insurance Authority and Organisation of its work.
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Date:

BROKER LETTER OF APPOINTMENT

To AXA Gulf,

This letter confirms that as of ___(dd/mm/yyyy)___, ________( y o u r n a m e )__________

have appointed Pacific Prime Insurance Brokers LLC as our exclusive insurance broker with respect to
all Medical Insurance policies. This appointment of Pacific Prime Insurance Brokers LLC rescinds all
previous appointments and the authority contained herein shall remain in full force until cancelling in
writing.

Pacific Prime Insurance Brokers LLC is hereby authorised to negotiate directly with AXA Gulf
with regards to all our health insurance needs including our renewal with them. This appointment
shall not however impose on them the responsibility for collection of unpaid premium, nor refund or
commissions or fees collected by the previously appointed Broker (unless by prior agreement). Note
also that Pacific Prime Insurance Brokers LLC does not accept responsibility for historical insurance
placement and/or arrangements that were arranged by another party prior to our appointment, until
relevant technical reviews have been completed.

Accordingly, this letter constitutes your authority to furnish representatives of Pacific Prime
Insurance Brokers LLC with all co-operation and information they may request as it pertains to our
insurance contracts, rates, rating schedules, reserves, retentions, claims files, and all other data they
may wish to obtain, both current and historical. We request you do not communicate such information
to anyone else.

Yours Sincerely,

______________________

Name and Signature

 Pacific Prime – AXA

Pacific Prime Insurance Brokers LLC is one of the world’s largest international private medical insurance
(IPMI) Intermediaries and we work with all the leading international insurance companies globally. We
have worked successfully with AXA Gulf for a number of years and we are finding their plans to be some of
the best ‘value of or money’ IPMI plans in the market today, offering extremely competitive premiums
considering the high level of coverage presented. Below are a few items we need to take note of:

Premium Sustainability:
From our experience, prices and service can change over time and so far, we have found AXA Gulf to be a
reliable insurer, however, we feel it is important to let our clients know that we believe the premiums and
benefits offered may not be sustainable in the long term. We would expect that there may be an increase in
premium, or reduction of benefits, for these plans in the future to bring them more in line with the
current market standards.

We feel it is important to make you aware that one of the key factors allowing AXA Gulf to offer premiums
that are considerably lower than other plans on the market is that the claims that are made on the plan
may affect the cost of the plan at your renewal.

Out-of-network Coverage:
We also strongly suggest you to stay within your network in order to benefit from outpatient direct
billing. Failure to use your selected networks can result in high co-insurance and partial reimbursement.
Please check your networks before proceeding with outpatient visits.

Declaration of Pre-existing Medical Conditions:

It is very important that you read Question 6 closely as this is designed to pick up any past/ongoing medical
conditions you may have/had. Pre-existing conditions are medical conditions or any related conditions for
which one or more symptoms have been displayed, irrespective of whether any medical treatment or
advice was sought.

Maternity Cover:
Please note AXA’s policy on the utilization of maternity benefits are only available to married women.

Should claims relating to maternity be made by a non-married woman they will not be covered.

If your marital status changes throughout the policy year, then AXA must be notified immediately with a
copy of your marriage certificate. Changing your marital status mid-term will incur a premium increase on
your policy.

Please note if the policy is being purchased with maternity benefits in mind, and a pregnancy declared
within the first 40 days, this is considered at the insurer’s discretion in line with DHA mandate.

Where a child is conceived between day 1 and 40 on the policy, this could result in an additional premium
applied by the insurer, or an exclusion on the pregnancy for the first year of the policy. Please also note
that if you are aware, you are pregnant prior to joining a plan it is imperative that the insurer be informed
upon application to avoid complications at point of claim.
AXA Gulf categorizes C-sections into two categories, elective or emergency. Where the client chooses to
have a C-section as part of their birthing plan, this will come from the standard maternity benefits.
Emergency C-sections are covered up to the annual limit of the policy and eligibility will be based on the
insurers review relating to the below conditions:

• Placenta Previa
• Pre-eclampsia and eclampsia
• Fetal distress
• Uterine rupture
• Umbilical cord prolapses

In addition, any newborn will be covered under the mother’s policy for the first 30 days from birth
for Dubai residence visa holders. However, this is not the case for newborns who are to be enrolled
on a Northern Emirates visa or when born outside the UAE. To be covered from day one of
birth, the insurer must be notified of this addition the same day of birth. DHA mandatory
screenings are only applicable for babies born within the UAE.

Payment Options
Moreover, your banking institution may allow you to adopt a payment plan for the purchase of this policy.
AXA Gulf will be paid in full and therefore, any subsequent monies owed will be between you and your
financial institution. Both AXA Gulf and Pacific Prime are here to support with anything relating to your
policy but would be unable to offer support with regards to your credit terms. In light of this, we would
always recommend an annual payment where possible as failure to keep up with these payments will be
handled as per UAE law.

At Pacific Prime Insurance Brokers LLC, we are dedicated to ensuring that our clients make the
most informed decision possible and by way of this we wish to ensure that you, our valued client,
are fully aware of all possible aspects of this plan in the future. We have a long-term dedication to
providing you with the best assistance with your international medical insurance.

Finally, kindly note, AXA GULF has been acquired by Gulf Insurance Group (GIG), one of the leading
insurers in the Gulf Region. There will be no impact to your medical coverage or policy in any way.
Essentially this means continuity to your medical insurance products, quotes, networks, membership cards,
services and benefits, all of which will remain unaffected and will continue to be supported by the pre-
agreed terms and conditions.

Name & Signature of Client

Date:
Contact Information
Why do we need this? We are here to assist you in the long term, with support on all administration, renewal and claims issues.
We request this form to be completed so we can contact you/your next of kin in case of emergencies or urgent policy issues.
People often forget to update their policy details when they move house or change employer and the below information helps
us to manage your policy better.
Please help us to achieve this by keeping us fully informed of any future changes in your contact details as soon as possible.
Pacific Prime guarantees your privacy, only using this information internally regarding issues relating to your, or your family’s,
personal insurance; will not provide this information to any third parties for commercial reasons.

Policyholder Spouse
Mr Mrs Ms Miss Other: Mr Mrs Ms Miss Other:
Family Name: Family Name:
Given Name: Given Name:
MiddleName(s): MiddleName(s):
Country: Country:
Home Address: Home Address:

Contact info in the country you now live in Contact info in the country you now live in
Mobile: Mobile:
Home: Home:
Work: Work:
Personal email (1): Personal email (1):
Personal email (2): Personal email (2):
Work email: Work email:
Employer: Employer:
Country: Country:
Employers Address: Employers Address:

Permanent contact information

Country: Country:
Mobile: Mobile:
Home/Work: Home/Work:
Email: Email:

Facebook:
Twitter:
Skype:
Google+:

Emergency Contact Person

In the event of an emergency whereby we are unable to contact you or your spouse or should you be
incapacitated then please provide us with the permanent contact details of an immediate family member
who we should contact in this situation.
Family Name: Email:
Given Name: Relationship to you:
MiddleName(s): Country:
Mobile: Home Address:
Home:
Work:
 Pacific Prime Insurance Brokers LLC
Room 110, The Offices
at Ibn Battuta Gate, Dubai
PO Box 391195
04 279 3800

THIRD PARTY AUTHORIZATION FORM

At Pacific Prime we are committed to handling your data in the most appropriate manner based on your
requirements. As standard practice, where there is communication relating to a specific member of the
policy who is over the age of 18, conversations would be had with that specific member where the subject
matter is related to them.

In this instance, we would require the below form completing in order to have the ability to contact insured
members over the age of 18. In its absence we will revert to the policy holder with whom conversation
have been had leading up to the inception of the policy.

1. Policyholder Details
Name:
Policy Number:
Contact Number:

2. Over 18 Dependent communication request

Spouse:
Name:
Email address:
Contact telephone number:
Signature:

Dependent 1:
Name:
Email address:
Contact telephone number:

Signature:

Dependent 2:
Name:
Email address:
Contact telephone number:

Signature:

Authorization
This authorization is valid with effect from: (DD/MM/YYYY).

Pacific Prime Insurance Brokers LLC is regulated and licensed by the UAE Insurance Authority (license number 266)