8/4/2019 Life Insurance Forms

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~ Pak-Qatar Family Takaful LimitedFamily Takaful

Health Declaration Questionnaire

EMPLOYER:

Address:

Father's Name/Husband's Name:

Day Month Year

Home Address:Telephone No.

Sex 0Male 0 FemaleCNIC No·1 I I I I I-I I I I I I I HdI Marital Status

Occupation Exact daily duties

Date of JoiningD.y Month Year

Date of Confirmation

D.y Mo-"m YouEmployer ID No.

Designation / Grade Annual Earned Income

Heightf~'

Weight Do you use tobacco or alcohol? 0No 0 YesSpecify quantity

SECTION 2 : MEDICAL DECLARA1ION (to be completed by prqposed employee) •

~ Before returning this form to younmpJoyer, please fQld a~d staple the bottom hall of the form to this line to~ ~conceal your answers to the medical questions below. " ' "_ ~ ... lIlt.

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D~O~

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ror females only: Are you pregnant, or have you ever had any gynecological, obstetrical or breast disease/medical condition?

Provide details for any "Yes" answers below. Use a separate sheet if necessary.

1. Have you had any injury, sickness, or ailment, or have you consulted or been treated by a healthcare provider for

any reason in the past five years?

6. During the fast 2 years, have you been involved in any type of hazardous occupation or avocation?

5. Do you contemplate any operati,on or visit to a doctor for an existing injury or ailment?

4. Do you take regular medication for treatment or control of any condition or ailment?

3. Are you now unable to work full time because of any disorder or disease?

2. Have you ever had:

A. High Blood Pressure, Heart Disease, or Arteriosclerosis? mn •••••••••••• uhu n ••••••••••••••••••••••••

B. Mental fitness, Stroke, or Epilepsy? _ nn. _ •• •• •• •• ••• •• •• •• u u • ••• •• • _ • ••• •• •• •• •• •• ••• •• h •• n •• •• •• •• ••• •• •• •• ••• •• •• •• •• •• ••• •• ••

C. Cancer, Diabetes, or Nephritis? .

D. Any problem with the back or spine? n •••••••••••••••••••••••••••••••••••••••••••••••••••••••••••••••••••••••••••••••••••••••••••••••••••

E. Acquired Immune Deficiency Syndrome (AIDS), AIDS related CDmplex (ARC) or an immune

system disorder? __ r. .

Example •• Road Traffic AccidclI t January. 2001 3 days hospitalization Fracture of Radius Dr. Saleem, AKUH, Karachi

Authorization and Declaration - Please read and sign below:

I hereby certify that all answers to questions appearing on this form are true and complete to the best of my knowledge and belief.

For Underwriting and claim puroses, r give my permission to: Any physician or other medical practitioner, hospital, clinic, other medical or medically related

facility,takidullinsurance company. or employer to give Pak·Qatar Family Takaful Limited or its authorized representative ALL INFORMATION on my behalf

including ('Opies of records with reference to any sickness, accident disability, treatment. examination medical investigation. advise or hospitalization underwent.

I hereby apply for the Family Takaful coverage under the terms and conditions of the master Participant Membership Document. In case, if the basis of coverage

is Contributory, r certify thai I shall pay the contribution mentioned above to the participant discontinuation of which terminates my takaful cover automaticaUy. In

case, howev •.r. if the basis of coverage is Non-Contributory, I c ertify and know that the discontinuance of Takaful Contribution by the participant on my behalf to the

Takaful Company will terminate my Family Takaful cover automatically .•

A photocopy of this form will be as vaJid as the original. [ate of Statement: Employee's SignatureDay Month Year Please aHi); your "ignaturc as on CNIC

Declaration by the Policyholder/Financer/Employer

l!We confirm that the information provided-above Is tnte to the best oE our knowledge, oo1 ief imd record. I /we agree 10 provide bene fi ts fo r t he e lig ib le prospect s under

the Participanfs Croup Tahftll Master Participant Membership Document. I/wc und~llOtand that lIuch benefits are payable subje.;:t to and in accordance with the terms

of lhe terms of Ma~ter Participant Membership Document, where appJicable,l/we agree to deduct the·n~sfl.ry contribuitons from the earning of the Individual Covered

under the scheme and to fonvard them promptly to Pak-Qatar Family ToIk..1fuJ Limited. 'This agreement shall cease to operate In respect of any person if he/she L'"eaBeS

to he member I empl(IY~ of the da~/ group covered under the Participant- M~bership Document from the dale of such discontinuance or on such earlier d~t~.as agreedwith the person COncern. In either case I/we undertake 10 notify the company accordingly .. ~..•

Date of Slatemenl: I Employer '. Signature I Iay Monlh Y~r ~--- _

Pll~dseaffj); officIal stamp/scal . ••••.ith sign,lfurtl