Medical Application Form

Below details are the member related information regarding their medical conditions

Member Information
Full Name:
Nationality: DOB: Gender:
Marital Status: Weight (Kg): Height (Cm):
Name of Principal: Relation:
Email Address: Mobile:

Member Medical Questions and Answers

# Question Yes No
1 Are you taking any prescribed medicine on a continuous/regular basis or have been
advised for the same?
.

Blood Pressure Pills Yes No Cholesterol Medications Yes No

Insulin Yes No Other Medications Yes No
If you replied yes to any conditions, please
specify and date of onset
………………………………………………………………..
………………………………………………………………..
.

2 Are you under any medical observation / undergoing any medical / surgical / treatment
or have been advised for the same?
.

Infectious & parasitic diseases Yes No Brain Disorder Yes No

Auto immune Diseases Yes No Spinal Surgeries Yes No
Kidney Yes No Lung Disorder Yes No
Cardiac Yes No Organ Transplantation Yes No
Portal Hypertension Yes No Other Yes No
Abdominal Surgeries Yes No If you replied yes to any conditions,
Operated/Non-Cancerous and completely recovered please specify and date of onset
Non operated/Cancerous ………………………………………………………………..
………………………………………………………………..
.

3 Do you have any chronic illness? or physical problem / disability that needs ongoing
long-term monitoring through consultations, examinations, check-ups, medications,
rehabilitation, physiotherapy, and/or tests?
.

Do you have Hypertension (Blood pressure)? Yes (Year of Onset: yyyy) No

Do you have Diabetes? Yes (Year of Onset: yyyy, Insulin) No
Do you have Hyperlipidaemia (Cholesterol) Yes No
Do you have Thyroid (gland near neck) or have tested for symptoms of Thyroid? Yes No
Do you have Blood Anaemia/ Thalassemia Minor?
Yes ( Aplastic, Sickle cell, Thalassemia Major) No

Do you have Liver disorders or illnesses? Yes No

Hepatitis A & E and history of Jaundice
Cholelithiasis (operated/treated and completely recovered Yes No)
If you replied yes to any conditions, please specify and date of onset

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 ………………………………………………………………..………………………………………………………………..

Do you have Genitourinary System disorders or illnesses? Yes No

Bladder infections/Urinary tract infections (Treated and completely recovered Yes No)
History of Kidney stones (Treated and completely recovered Yes No)
Prostate or related problems (non-cancerous and treated and completely recovered Yes No)
Urethral Strictures
If you replied yes to any condition, please specify and date of onset
………………………………………………………………..………………………………………………………………..
Do you have any of the disorders or illnesses or symptoms or diagnosis related to digestive
system? Yes No
Acid Reflux
Ulcers (Colitis/Crohn's Disease Yes No)
Diverticula (Operated Yes No)
Problems of the teeth/gums/mouth/jaw
Hernia non operated
Anal/Rectal polyps (Operated/Non-Cancerous and completely recovered Yes No)
Do you have any of the disorders or illnesses or symptoms or diagnosis related to physical
defect/disability or birth related disorders or congenital ailment? Yes No
If you replied yes to any condition, please specify and date of onset
………………………………………………………………..………………………………………………………………..
.

4 Have you ever been diagnosed / treated and cured or undergoing treatments for
cancer?
.

Do you have any history of benign tumours? Yes ( Operated / Non Operated) No
Other types of cancer (past/ongoing treatment)? Yes No
If you replied yes to any condition, please specify and date of onset
………………………………………………………………..………………………………………………………………..
.

5 Is there any other medical condition or disorder or any symptoms that should be
declared, and you are unable to relate to the above-mentioned Questions?

If yes, please describe and date of onset:

6
Are you consuming Alcohol, tobacco and/or drugs? Yes No
If you replied yes to any condition, please specify and date of onset
………………………………………………………………..………………………………………………………………..

7
Have you ever suffered Mental/psychiatric disorders? Yes No
If you replied yes to any condition, please specify and date of onset
………………………………………………………………..………………………………………………………………..

8 Are You Currently Pregnant or trying to get pregnant?

Last menstrual cycle date: DD/MM/YYYY
Are you undergoing any form of fertility treatment? Yes No
.

If Pregnant, Which trimester are you currently in First Second Third

Are you having earlier history of Caesarean Section, Premature Delivery, miscarriage or
complications during /after pregnancy? Yes No

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 Is it multiple pregnancy? Yes No

Are you having earlier history of Caesarean Section, Premature Delivery, miscarriage or
complications during /after pregnancy? Yes No
If you replied yes to any condition, please specify and date of onset
………………………………………………………………..………………………………………………………………..
.

Disclaimer
I hereby undertake that all above information are correct and the acceptance of my application will be on the basis of
such information and that United Fidelity Insurance Company has the right to contact any physician, medical facility or
other institution or person, that has any records or knowledge of my health or the health of any of my dependents if
applicable to assess the risk(s) to assess the risk(s). I hereby confirm that the United Fidelity Insurance Company has
the right to reject the coverage/claims in full in case of no declaration of any cases prior to the contractual date or
before application or adding a new Insured during the contract. I, the undersigned declare that all the above
information as well as all declarations on the questionnaire (personal information) are true and complete. This
information shall be considered as an integral part of the insurance policy. I hereby give my consent to the use,
disclosure, and processing of all my personal and medical information (and my Independents if applicable) for the
purposes related to my insurance policy.

Maternity Clause
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.

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MEDICAL CONDITION PAGE
Name of Applicant: ____________________________ Age: __________ Sex: ____________

Medical Condition/Diagnosis (If more than one sickness, please complete a separate form for
each):
_______________________________________________________________________________

Date of Last Treatment/Symptoms (dd/mm/yyyy): _____________________________________

Diagnosis Status (Please tick relevant box): Yes No

1. Cured / No Symptoms
2. Ongoing Symptoms
3. Ongoing Hospitalization
4. Pending Hospitalization
5. Ongoing Treatment
6. Pending Treatment
In case of any Diagnosis Status the applicant was treated as (Please tick relevant
Yes No
box):
1. Outpatient
2. Hospitalized
3. Treated both ways
Date of Operation (dd/mm/yyyy):
How often do the symptoms occur? Or can the illness be described as follows?
Yes No
(Please tick relevant box):
1. Acute
2. Chronic
3. Recurrent
Others: (Please tick relevant box): Yes No
1. Did you have any bone fractures or injuries to bones or tendons?
2. Has any material used for osteosynthesis etc. been removed?
3. In case of diabetes, please specify whether insulin dependent.

4. In case you are suffering from hypertension, please specify your Systolic __________ and Diastolic _________.

In case medication is required on a regular basis, please specify the genuine name, the brand name,
as well as the daily/weekly quantity on the below.

Applicant Signature: ______________________ Date: _________________________

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By Signing this document, you hereby accept this “Privacy Policy”:

This Privacy Policy sets out the basis on which any confidential, personal and sensitive information,
you provided to us related to you or/and your dependents or any other person covered under
Fidelity United Policy (Personal Data).
You hereby give us your unconditional consent to:
1. Contact you anytime, through any means (email, SMS, phone, etc.) and for any reason;
2. Collect, process and store your information including any Personal Data which you will
provide/provided to us (including by way of cookies) for the time period as required by us;
3. Transfer your Personal Data including but not limited to third party administrators, medical
providers, brokers, agents, service providers, lawyers, etc (Third Party Partners), whether
inside or outside the UAE;
4. Use your Personal Data as required by us for evaluating/ underwriting/ issuing/
administering/ processing your policy or/and claims
5. Disclose your Personal Data to Third Party Partners as required to issue/ underwrite/
administer / process your policy/ claims, etc. within or outside the UAE.
6. Disclose and/or report your Personal Data to legal/regulatory agencies/bodies if and as
required by law.

Fidelity United does not disclose this information to third parties except as required to provide
service(s) to you, to carry out the transaction(s) you have requested, to operate the Fidelity United
Site, or as required by law or any court of competent jurisdiction.

You will ensure that all Personal Data provided to us is accurate and, where appropriate, kept up to
date, and you will notify us if you become aware that such data is inaccurate.

You will provide us with reasonable assistance, upon request, in dealing with any requests, inquiries
or complaints that we receive from data subjects and/or supervisory authorities in relation to any
Personal Data processed.

I, the undersigned, ……………………………………. I hereby confirm that This Privacy Policy has
been read and fully understood and I hereby agree that by signing this form I provide my
unconditional consent on all the above-mentioned.

Signature: _______________________ Date:

Print Name: ______________________

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