Health Takaful Form. Adult
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- Cecil Stanley
- 5 years ago
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1 Application Form Proposal no. no. no: no. Health Takaful Form Please Choose the Takaful Health Plan of Interest Al-Shifa Basic Al-Shifa Excel If Familyt Health Takaful, please specify the number of members proposed Adult Ch ildren (under 18 Years) IMPORTANT NOTICE Please read through the following notes that are relevant to any of either certificate you may enroll under. 1. Any of either certificate may have a proposer, maximum aged 59 years when applying for the plan. 2. Family certificate holders may have a dependent spouse of maximum age of 59 years when applying for the plan. 3. Family certificate holders may have dependent Unmarried ren under 21 years of age when applying for Takaful. 4. Any of either certificate proposers may continue health takaful up to the age of Under family takaful, a dependent spouse may continue in the plan ll the age of Under family takaful, dependent children may continue plan up to the age of 21 years when unmarried. 7. All documents of Medical Check-up as per the Check List provided would not be reimbursed under any of either takaful plan. 8. The takaful plan is only for those residing in the Maldives for more than 6 months in a 12 months period. This is not for overseas travelers who remain out of the country for a period more than 6 months. 9. Certificate Coverage is for 12 months period from the issue of Takaful, whereby the takaful plan need be renewed before the end of the period. A. Your Personal Particulars Title Mr/Ms/Mrs/Dr ID no. Male Female Date of birth Age Weight kg Height cm Nationality Nature of Work Person engaged in professional, administrative, managerial, clerical and non-manual operations Persons engaged in work of supervisory nature but not involved in manual labor Persons engaged occasionally or generally in manual work which involves the use of tools or machinery Coverage Option 1 Inpatient Only Outpatient Only Option 2 (discount applied) Family Outpatient B. Your Dependents Particulars (Only if the Family Takaful Scheme is required) Full Passport/ID No. Age Date of Birth Nationality Weight Height
2 C. Declarations 1. Do you or any of the persons to be covered have Health Insurance/Takaful with or any other company? If Yes, please attach a copy of the existing policy schedule Application Proposal no. no: Yes No 2. Have you or any of the persons to be covered as your dependents: A. Suffered or have any physical defects, infirmity or congenital conditions? B. Currently under observation or receiving treatment or taking any medication? C. Undergone any surgical operation or suffered any disease or injury? D. Ever been advised to have a surgical operation which has not been performed? 2. Have you or any of the persons to be covered as your dependents: A. Chronic cough, spi ng of blood, asthma, hay fever, pleurisy, tuberculosis or any other disease of the respiratory system? B. High or low blood pressure, heart disease, chest pain, heart a ack, shortness of breath, palpita on or any other heart disorder? C. Epilepsy, fits, dizziness, mental or nervous disorder? D. Diabetes, sugar or blood in urine, kidney, colic or hernia? E. Disease of the eyes, ears, nose or throat? F. Arthritis, sciatica, rheumatisms, back, spine, bone, joint, muscle or rectal disorder? G. Ulcer or disorder of the stomach. Intestines, hemorrhoids or rectal disorder? H. Gall bladder stone or liver disease or any type of hepatitis? I. Cancer, tumor or growth of any kind of any organ system? J. Anemia, thyroid disorder (such as Goiter) or Rheumatic Fever? K. Sexually transmitted disease such as syphilis, gonorrhea or non-specific arthritis? L. AIDS or AIDS-related conditions? M. Smoking/Chewing Tobacco? If Yes, please specify. per day. If more than one person smokes please write in the respective order of the check marks N. Any illness or injury not mentioned above? O. Any other form of Addition? If Yes, please specify. 4. If any of the answers is Yes to questions in 2 & 3, please give details below and number your answers to correspond with the number of the questions to which the answer is applies.
3
4 D. Further Personal Particulars: Blood Type Usual Doctor/Physician of Choice: Address: Known Allergies: E. Insurance/Takaful History: 5. Have you or your dependents application for medical or hospitalization type of policy been declined, restricted or accepted at other than normal terms? If Yes, please state reason and provide the name of the Insurance/ Takaful Company. Reason F. Contact Information: Contact person Contact no. Secondary Contact Contact no. Preferred Bank account number to transfer yearly Surplus Bank Account Account Number Declaration: I/We agree to participate in this Takaful scheme based on the principle of Ta awun and to pay the contribution on the basis of TABARRU (donation) for the purpose of helping each other participants who have suffered a financial loss due to any of the covered event (s). Based on this contribution, I/we are also entitled to the Takaful cover subject to the terms and conditions of this contract. I/We further agree that my/our contribution be credited into the Risk Fund (PRF) and to appoint AYADY TAKAFUL to manage and invest the Fund according to Islamic Shariah. I/We also permit AYADY TAKAFUL to make payment for claims/takaful benefits, provisions and reserves based on the guidelines and policies laid by the authorities, and to pay a WAKALAH (agent) fee at the rate of 30% of the contribution to AYADY TAKAFUL. I/We further agree that the money in the PRF shall be invested by AYADY TAKAFUL, and if the return from the investment exceeds 1.2%, the additional return or excess shall be retained and credited to AYADY TAKAFUL under the principle of PERFORMANCE FEE (Ujrah). Additionally, I/We authorize AYADY TAKAFUL to distribute Net Surplus of the PRF at the end of the year (if any) among the participants. I/We understand that this Takaful Certificate will not be enforced unless this proposal has been accepted by AYADY TAKAFUL. ބ ޔ ނ : އ ހ ރ ނ /އ ހ ރ މ ނ އ އ ބ ސ މ ވ ނ ތ ޢ ވ ނ ގ އ ސ ސ ތ ކ ގ މ އ ޗ ށ ބ ނ ވ ފ އ ވ އ ނ މ ތ ކ ފ ލ ސ ކ މ އ ގ އ ބ އ ވ ރ ވ މ ގ ގ ތ ނ ތ ބ އ ރ ޢ (ހ ލ އ ހ ) ގ އ ސ ލ ގ މ ތ ނ ފ އ ސ ދ އ ކ މ ށ ވ. މ އ މ ނ ޒ މ ގ ދ ށ ނ ބ އ ވ ރ ވ އ ނ މ ނ ނ ށ މ ލ ބ މ ލ ގ އ ލ މ އ ފ ބ އ ދ މ ށ ޓ ކ އ އ ކ ކ އ ނ ކ ކ ށ އ ހ ތ ރ ވ ވ ނ ޒ މ ކ ވ. މ ނ ޒ މ ގ ދ ށ ނ އ ހ ތ ރ ކ ނ ފ ރ ކ ށ ދ ވ ނ ތ ކ ފ ލ އ އ ބ ސ ވ މ ގ އ ކ ނޑ އ ޅ ބ ޔ ނ ވ ފ އ ވ ފ ދ ޙ ލ ތ އ މ ދ ވ ރ ވ ގ ނ ލ ބ މ ލ ގ އ ލ މ އ ފ ބ އ ދ ށ ވ. މ ތ ކ ފ ލ ސ ކ މ ގ އ ބ އ ވ ރ ވ މ ށ ދ އ ކ ފ އ ސ ބ އ ވ ރ ނ ނ ށ އ ހ ވ ފ ނ ޑ ށ (ޕ.އ ރ.އ ފ އ ށ ) ޖ މ ކ ރ މ ށ ރ ހ ޤ ބ ލ ވ މ ވ. އ ދ މ ފ އ ސ އ ނ ބ އ ވ ރ ނ ނ ށ އ ހ ވ މ އ ޤ ވ އ ދ ތ ކ ގ ދ ށ ނ ކ ރ ނ ޖ ހ އ ހ ނ ހ ނ ޚ ރ ދ ތ އ ކ ރ މ ގ ހ އ ދ އ ޔ ދ ތ ކ ފ ލ އ ށ ދ މ ވ. އ ދ އ ސ ލ މ ޝ ރ ޢ ތ ހ އ ދ ކ ރ މ ގ ނ މ ފ ނ ޑ ގ ފ އ ސ އ ނ ވ ސ ޓ ކ ރ މ ށ އ ޔ ދ ތ ކ ފ ލ އ އ ޔ ނ ކ ރ މ ވ. މ މ ޢ މ ލ ތ ތ އ ކ ރ މ ނ ލ ބ ނ ވ ވ ކ ލ ގ ފ ގ ގ ތ ގ އ 30% (ތ ރ ސ އ ނ ސ އ ތ ) އ ޔ ދ ތ ކ ފ ލ އ ށ ދ ނ މ ށ ވ ސ އ އ ބ ސ ވ މ ވ. އ ދ އ ހ ވ ފ ނ ޑ ށ ޖ މ ވ ފ އ ސ އ ނ ވ ސ ޓ ކ ށ ގ ނ ލ ބ ފ އ ދ 1.2% (އ ކ އ ޕ އ ނ ޓ ދ އ އ ނ ސ އ ތ ) އ ށ ވ ރ އ ތ ރ ވ ނ މ އ ތ ރ ވ ބ އ އ ޖ ރ އ ގ ގ ތ ގ އ އ ޔ ދ ތ ކ ފ ލ އ ށ ޖ މ ކ ރ މ ށ އ އ ބ ސ ވ މ ވ. މ ގ އ ތ ރ ނ އ ހ ރ ނ މ އ ރ ބ އ ވ ރ ނ ނ ށ އ ހ ވ ފ ނ ޑ (ޕ.އ ރ. އ ފ ) ގ އ ޚ ރ ދ ތ އ ކ ނޑ އ ފ އ ދ އ އ އ ތ ރ ވ ނ މ އ ފ އ ދ ކ ނޑ އ ޅ ފ އ ވ އ ސ ލ ގ މ ތ ނ ފ ނ ޑ ގ ބ އ ވ ރ ނ ގ މ ދ ގ އ ބ ހ މ ށ އ ޔ ދ ތ ކ ފ ލ އ ށ ހ އ ދ ދ މ ވ. އ ދ މ އ އ ބ ސ ވ ނ އ ޔ ދ ތ ކ ފ ލ ގ ފ ރ ތ ނ ބ ލ އ ފ ރ ހ މ އ ށ ޤ ބ ލ ކ ރ މ ނ މ ނ ވ އ އ ބ ސ ވ މ ށ ޢ މ ލ ކ ރ ނ ނ ފ ށ ނ ކ މ ށ އ ހ ރ ނ /އ ހ ރ މ ނ ޤ ބ ލ ކ ރ މ ވ.ދ Signature ސ އ Date ތ ރ ހ Office use only Rate: Contribution: Agent s : THIS APPLICATION WILL NOT BE IN FORCE UNTIL THE APPLICATION HAS BEEN ACCEPTED BY THE TAKAFUL OPERATOR މ އ ޕ ލ ކ ޝ ނ އ ށ އ މ ލ ކ ރ ވ ނ ފ ށ ނ ތ ކ ފ ލ އ ޕ ރ ޓ ރ އ ޕ ލ ކ ޝ ނ ބ ލ އ ގ ތ މ ނ ނ ވ. You are to disclose in the application form, fully and faithfully all the facts which you know or ought to know, otherwise the certificate issued here under maybe void. މ އ ޕ ލ ކ ޝ ނ ފ ރމ ގ އ ވ ހ ރ ހ މ އ ލ މ ތ ކ ތ ޔ ފ ރ ތ ށ އ ނގ ފ އ ވ އ ދ އ ނގ ނ ޖ ހ މ އ ލ މ ތ ށ ބ ނ ކ ށ ފ ރ ހ މ ކ މ އ ތ ދ ވ ރ ކ މ އ އ ކ ދ ފ އ ވ މ އ ލ މ ތ ށ ވ ނ ވ ނ އ ވ. މ ނ ނ ގ ތ ކ ށ މ އ ލ މ ތ ހ މ ނ ފ އ ވ ނ މ މ އ ޕ ލ ކ ޝ ނ އ ށ ދ ކ ރ ވ ތ ކ ފ ލ ވ ނ ބ ތ ލ ތ ކ ފ ލ އ ކ ށ ވ.
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