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Orient Insurance Maternity Coverage Form

This document contains a health insurance application form requesting details about a dependent to be added to a policy. It requests information such as name, date of birth, height, weight, gender, email, mobile number, relationship to sponsor, medical history, and pregnancy details if applicable. The applicant must acknowledge that any non-disclosed medical conditions or pregnancies may not be covered by the insurer.

Uploaded by

Md Morshadul Alam
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© All Rights Reserved
We take content rights seriously. If you suspect this is your content, claim it here.
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30 views3 pages

Orient Insurance Maternity Coverage Form

This document contains a health insurance application form requesting details about a dependent to be added to a policy. It requests information such as name, date of birth, height, weight, gender, email, mobile number, relationship to sponsor, medical history, and pregnancy details if applicable. The applicant must acknowledge that any non-disclosed medical conditions or pregnancies may not be covered by the insurer.

Uploaded by

Md Morshadul Alam
Copyright
© All Rights Reserved
We take content rights seriously. If you suspect this is your content, claim it here.
Available Formats
Download as PDF, TXT or read online on Scribd

9/5/23, 3:16 PM Orient Insurance

Health Insurance

Insured details

Dependent  

* First Name

Middle Name

* Last/Family Name

Maiden Name

* Date of Birth (DD/MM/YYYY)

Married  

* Height(in Cm)

* Weight(in Kg)

Gender
Female  
Scan Eid
Scan ID

* Email Address
eg:name@[Link]

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* Mobile No(start with 971)


eg:971xxxxxxx
* Policy Term  

* Relationship to the Sponsor  

Do you hold Dubai Visa?


--Select--  

Have you any pre-existing condition/ have been diagnosed and / or treated for any Chronic
condition as listed?
--Multiple selection possible--  

Have you ever been diagnosed and/or treated for any Critical cases as listed?
--Multiple selection possible--  

CORPORATE CODE IF APPLICABLE

* Salary of Sponsor  

Declarations Yes / No

Are you Pregnant ?


Yes No
Maternity benefit is applicable only for Married Females between 18-45 years old

Have there been any complications to date ?


Yes No

Last Menstrual period date

* Last Menstrual period date (DD/MM/YYYY)


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 and
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 answer.

Any non-disclosure, misrepresentation, or concealment of material fact will make this policy void
with immediate effect without any entitlement for refund.
Enter the characters shown in the image

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9/5/23, 3:16 PM Orient Insurance

Proceed to next

Plan details

Insured's additional details

Sponsor details

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