Medical Application Form

Insured Application Date:

Name:
Required Plan: Cilinc + hospital cover in Application/Policy No.:
Abudhabi City

Current Address: ………Villa No 25, Zone 22, Mohammed bin Zayed City, Abu Dhabi
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 Self and Family Insurance details for ALL members:

Heigh
NAME Relation
t

First Middle Self Emirates Already

Marital D. O. B. Nationality CM Weight UAE
Last /S/C M/F ID card Insured Previous
Status DD/MM/YY KG
(Yes/No)
Resident

Yes/No Yes/No
Sreenivasula
Reddy Self Married 16/05/1985 Indian M 164 70 Yes Yes No NA NA NA NA
Tadigottla

Is there a member in your family that is not proposed for Insurance? Yes/No
If Yes, Kindly share reason for each member
……………………………………………………………………………………………………………………………………………………
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 Active at work Since: ……………05-Sep-2023……………………

 Insurance History (in case answer is "Yes," specify reason/ details)

a. Have you ever been accepted for life and/or health insurance on sub-standard terms?
b. Have you ever been declined for life and/or health insurance?
 Do you participate or intend to participate in any amateur/professional/hazardous sport activities? Yes/No
If Yes, …………………………………………………………… …………………………………………………………………….
Have you ever been diagnosed or received any treatment (including hospital or surgery) or felt any disorder or pain or had any symptoms indicating:
(Please tick relevant box) Yes / No Yes / No
1. Infectious and parasitic diseases 13. Musculoskeletal and/or Connective Tissue
System? (I.e. fractures, joint or cartilage problems,
No No
back problems, bone infections, osteoporosis,
arthritis, rheumatism, etc.)

2. Cancer, Neoplasms, Tumors? (specify below 14. Congenital anomalies, hereditary/genetic

the type, location, treatment, whether malignant or No diseases No
benign)

3. Diseases of the endocrine system, nutritional-, 15. Certain conditions originating in the perinatal
metab Endocrine, Nutritional, Metabolic and/or No period No
Immunity System? (i.e. diabetes, thyroid or pituitary
gland problems, adrenal gland, ovary or testes
problems, hormone problems, gout, multiple
sclerosis, cystic fibrosis, metabolic disorders,
immune problems, etc.)Colic diseases and
immunity disorders, diabetes
4. Blood & Blood Forming Organ Systems? (i.e. No 16. Injury and poisoning No
anemia, thalassemia, bleeding disorders, blood cell
disease, spleen problems, lymph node problems,
etc.)
5. Mental-/psychiatric disorders 17. Previous medical/surgical hospitalizations,
No procedures and operations No

6. Nervous System or Sense Organs? (i.e. ear 18. Any (chronic) disease(s), symptoms and
No No
injury/infection, vertigo, hearing problems, eye complaints not mentioned above
injury/disease, retina problems, glaucoma, vision
problems, muscular dystrophy, brain/nerve
degeneration, meningitis, paralysis, seizures,
epilepsy, neuralgia, etc.)
7. Cardiovascular System? (i.e. stroke, cerebral 19. Any Pre-existing disease(s), symptoms and
ischemia, rheumatic fever, atherosclerosis, No complaints I within the last ten years Yes
aneurysm, embolism, peripheral vascular disease,
hypertension, heart valve disease, irregular
heartbeat, pulmonary embolism, phlebitis,
varicosities, etc.)
8. Respiratory System? (i.e. Sinusitis, allergies, No 20. Have you ever undergone surgery to remove a No
tonsillitis/laryngitis, bronchitis, emphysema, body organ or structure or being hospitalized in the
pneumonia, etc.) past? (Specify body organ/Structure, date & place
of surgery?)
If Yes, have there been any complications to date?
9. Cirrhosis/ Hepatitis / Wilsons disease / 21. Are you presently in good health, entirely free
No No
Pancreatitis/ Liver disease / Cohn’s disease / from any physical/mental impairment and
Ulcerative Colitis /Piles or any other disease of deformity? If no please provide the details
Mouth , Esophagus , Liver , Gall bladder , Stomach
or Intestines or any other part of Digestive System?

10. Genitourinary System? (i.e. Kidney/bladder No 22. Has there been any Loss/Gain of wait in last 12 No
infections, renal failure, kidney stones, months? Yes No (If yes please provide details)
endometriosis, menstrual cycle problems,
salpingitis, ovarian cysts, prostate problems,
impotence, testicle infections, sperm abnormalities,
fertility problems, Breast disorder etc.)
11. Do you have earlier history of Caesarean No 23. Smoke, consume alcohol, or chew tobacco or No
Section, Premature Delivery or Premature babies? use any recreational drugs? If Yes please then
Or any other complications related to maternity, till provide the frequency and amount consumed
date?

24. Have you ever suffered from dental problems? YES/NO

(b) If, yes, specify same.
(c) When were you treated last for same?
 Please Note:
1. In case the answer is YES to any of the conditions/diseases above, please specify full details (preferably by a
Medical Physician) on the additional questionnaire (Personal Information), which will be found attached to this
application form.

I am having the Thyroid Problem from Last 5 Years and using medication
regularly.

2. In case medication is required on a regular basis please specify the full details such as genuine name, brand
name and daily/weekly quantity on the additional questionnaire (Personal Information), which will be found
attached to this application form.

I am using Thyroxine sodium Tablets for Thyroid Treatment. Brand Name:

Thyronorm (75mcg), Dosage is One tablet per Day

For Married Females:

Yes No
- Are you currently pregnant?
- If yes, have there been any complications to date? -
- Last Menstrual period date:
- Are you currently trying to get pregnant?
- Are you undergoing any form of fertility treatment?

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, shall not
be covered under this policy under any condition.

I agree that no indemnity will be paid under the proposed insurance policy for medical expenses arising from disorders which
were declared prior to completion of this Application and which were not disclosed to the insurer at the date of this application.
Failure to disclose material information to the insurer will invalidate the proposed insurance policy.

I hereby declare and agree, with respect to both, myself and to my Dependents, that I am aware of the general terms of this
insurance and I accept them. With the above, I authorize my doctor, previous Insurer, Previous TPA, health institution or other
organization or person that has any information about my health and/or activities (and those of my Dependents) to provide the
Insurer with the said information. This shall include hospital and any other records pertaining to medical advice, diagnosis,
treatment or disturbances. A photocopy of this authorization has the same validity as the original.

I the undersigned declare that all of the above information as well as all declarations on the additional questionnaire (personal
information) are true and complete. This information shall be considered as an integral part of the insurance policy.

Date: Signature:

Note: To be treated as confidential once completed

 Medical Conditions

Name of applicant: Sreenivasula Reddy Tadigottla Age: 38 Sex: Male

Date of application: 01/11/3023 (dd/mm/yyyy)

Medical condition/diagnosis:
(if more than one sickness, please complete a separate form for each)

Date of last treatment/symptoms: / / (dd/mm/yyyy) ongoing treatment = Thyroid

current date

Diagnosis Status: Yes No

 Cured/ no symptoms

 Ongoing symptoms
 Ongoing hospitalization
 Pending hospitalization
Yes
 Ongoing treatment
 Pending treatment

In case of any Diagnosis Status the applicant was treated as:

 Outpatient Yes

 Hospitalized
 Treated both ways
 Operated on: / / (dd/mm/yyyy)

How often do the symptoms occur? ………………………No Symptoms…………………

Or Can the illness be described as follows?

No
 Acute No
 Chronic No
 Recurrent

Did you ever have any bone fractures or injuries to bones or No

tendons? Has any material used for osteosynthesis etc. been No

removed?

Any dimness of vision or cataract etc No

No
Have you been tested or treated for Hepatitis A or C?

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

… Thyroxine sodium, Thyronorm 75mcg, one Tablet per Day

…………………………………………………………………………………………….

In case you are suffering from hypertension please specify your Systolic and Diastolic readings below.
Systolic:
Diastolic:

In case of diabetes please specify whether insulin dependent,

please specify the generic name / brand name as well as the daily / weekly quantity below
KNOW YOUR CUSTOMER FORM (KYC) – INDIVIDUKNOW YOUR CUSTOMER FORM (KYC) – INDIVIDUALKNAL

MEDICAL PRACTITIONER(S) MOST FREQUESNTLY VISITED IN THE LAST 2 YEARS:

• Name:
• Address:
• Telephone No.:

CANCER

Are you suffering or ever suffered with any type of Cancer? Yes/no

If Yes, kindly share the current status

a. Cured/ no symptoms
b. Ongoing symptoms
c. Ongoing hospitalization/ Treatment
d. Pending hospitalization/ Treatment

Kindly provide full details of past, current or advised pending treatment:

a. Diagnosis
b. Surgery
c. Chemotherapy cycles
d. Radiotherapy cycles
e. Radiation cycles
f. All other medication

Do you have any FAMILY HISTORY of Cancer? Yes/No

If Yes, provide details
……………………………………………………………………………………………………………………………………………………………
…………………………………………………………………………………………………………………………………

Date: Signature:

Note: To be treated as confidential once completed

KNOW YOUR CUSTOMER FORM (KYC) – INDIVIDUKNOW YOUR CUSTOMER FORM (KYC) – INDIVIDUALKNAL

KNOW YOUR CUSTOMER FORM (KYC) – INDIVIDUAL

Important Instructions: Fill the form completely & mark NA where Not Applicable

INSURANCE DETAILS

Application Type ☐ New ☐ Renewal

Class of Insurance required Silver or Silver Premium

APPLICANT DETAILS
Sreenivasula Reddy Tadigottla
Full Name as per ID

Date of Birth 16-May-1985 Place of Birth Hyderabad, India

Gender ☐ Male ☐ Female

Nationality Indian

Mobile no +971401459353

Email Address Sreenivas040@[Link]

Residential Status ☐ UAE Citizen ☐ Resident ☐ Non-resident

Villa No 25, Zone 22, Mohammed bin Zayed City, Abudhabi
Address in UAE

☐ Salaried (Private Sector) ☐ Salaried (Public Sector)

Occupation Type ☐ Business Partner/Owner ☐ Freelancer
☐ Unemployed
Triniti Middle East Fz LLC -DBA
Employer Name & Address

Job Title Software Engineer

☐ Below AED 15,000 Yes

Monthly Income
☐ Above AED 15,000
In the last 6 months, have
you submitted any KYC ☐ Yes ☐ No
documents to
DIN
If yes, For which class of
Insurance

IDENTIFICATION DETAILS

ID Type ☐ Emirates ID ☐ Passport ☐ GCC ID

*
ID Number 784198523665242

ID Expiry Date 17/09/2025

POLITICAL EXPOSED PERSON (PEP) DECLARATION: Natural persons who are or have been
entrusted with prominent public functions in the State or any other foreign country such as Heads of
States or Governments, senior politicians, senior government officials, judicial or military officials, senior
executive managers of state-owned corporations, and senior officials
of political parties and persons who are, or have previously been, entrusted with the management of an
international organization or any prominent function within such an organization.
Do you classify yourself as a PEP or are you a direct relative or known
associate of a PEP If Yes, please specify details of PEP

Name

Title/Designation

PEP Type ☐ Domestic PEP ☐ Foreign PEP☐ Head of International Organizations

(HIO)

PAYER DETAILS (IF PAYMENT IS MADE BY A THIRD PARTY)

Name

Nationality

Relationship

ID Number

ID Expiry Date
☐ Below AED 15,000
Monthly Income
☐ Above AED 15,000

CUSTOMER DECLARATION
☐ I declare that the above details are true and correct to the best of my knowledge and belief. I
undertake to inform you of any changes in the above information. In case any of the above
information is found to be false or misrepresented, I am aware that I will be held accountable
and liable for legal action.

☐ I hereby also confirm that I am not a resident for Tax purpose in any country other than UAE,
though one or more parameters may suggest my relationship with the country outside UAE.
Therefore, I am providing my Emirates ID document as proof of my citizenship or residency in
the UAE region.

☐ I hereby confirm that I am NOT a US person as defined in the FATCA regulations.

__ ____________________
Signature of the Customer Date: 02/11/2023
Note: The KYC Documents, information, and PEP Declaration should be collected in accordance with the Central Bank Directive
and Cabinet Decision No. (10) Of 2019. Any information shared with DIN will be treated with utmost confidentiality and will be
utilized strictly by the AML Compliance team of DIN and there are no cross border transfer of any data carried out by the staff of
DIN, except at an event of an adverse situation where DIN would be obliged to provide the information requested by the Law
enforcement authorities and or Supervisory Authorities (CBUAE, Financial Intelligence Unit or the Executive Office, etc.) of UAE.