HEALTH INSURANCE PROPOSAL FORM SELECT AND SELECT XL

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HEALTH INSURANCE PROPOSAL FORM SELECT AND SELECT XL Proposal no. Policy no. Individual cnudurwf wlcaimwa Company inufcnuk National ID Card cdwk.id.iawa Registration Certificate ctekifctes IrcTcsijwr Occupation: WriaWd egwfizwv Nature of Business: ctwvwb egirwfwyiv Work Permit ctimrwp ckov Passport ctopcswp Company/Office/Applicant s Name: cnwn egutcnwkilcpea /cnwn eguhifoa /cnwn eginufcnuk ID No. urwbcnwn ID.iawa Date of Birth: ckirwt cnwfua Male cnehirif Female cnehcnwa Reg No. urwbcnwn IrcTcsijwr Permanent Address (as in ID card): (cswtogwv iawgudwk IDwa) csercdea ImiaWd Nationality: umuawg Postal Address (fill below): csercdea WrukuTcsOp Contact Name: cnwn egwhim ELug House/Building name: cnwn egutwrwmia /cnwnegeg Contact No: urwbcnwn egwhim ELug Road: ugwm Postal Code: cdok clwtcsop District: cswvwa Atoll,Isand: cswr,ulotwa Email: clemia Fax: csckef Please Choose the Policy of Interest SELECT SELECT XL If Family Insurance, please specify the number of members proposed. Adult Children (Under 18 years) IMPORTANT NOTICE Please read through the following notes that are relevant to any of either policy you may enroll under. 1. Any of either policy may have a proposer, maximum aged 59 years when applying for the policy. 2. Family policy holders may have a dependent spouse of maximum age of 59 years when applying for the policy. 3. Family policy holders may have dependent Unmarried Children under 21 years of age when applying for insurance. 4. Any of either policy proposers may continue health insurance up to the age of 65. 5. Under family insurance, a dependent spouse may continue in the policy till the age of 65. 6. Under family insurance, dependent children may continue policy 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 policy. 8.The policy 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. Policy Coverage is for 12 months period from the issue of Insurance, whereby the policy need be renewed before the end of the period. Allied Insurance Company of the Maldives Pvt. Ltd. (C-43/84), Fen Building, 3rd floor, Ameenee Magu, Male, 20375, Maldives +960 330 0033 +960 332 5035 info@allied.mv youtube.com/alliedmv facebook.com/alliedmv twitter.com/alliedmv allied.mv

Nature of Work (Please tick whichever is applicable) Insured Person engaged in professional, administrative, managerial, clerical and non-manual operations. Insured Persons engaged in work of supervisory nature but not involved in manual labor. Insured Persons engaged occasionally or generally in manual work which involves the use of tools or machinery. Coverage Inpatient Only (Discount applied) Family Your Dependents Particulars: Only if the Family Insurance Scheme is required Full Name Passport/ID No. Age Date of Birth Nationality Weight Height Declarations: 1. Do you or any of the persons to be insured have Health Insurance with us or any other company? If Yes please attach a copy of the existing policy schedule. Yes No 2. Have you or any of the persons to be insured as your dependents: None 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?

3. Have you or any of the persons to be insured as your dependents ever been told that you or they have suffered from or had been treated for any of the following? None A. Chronic cough, spitting 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 attack, shortness of breath, palpitation 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 questions to which the answer is applied.

Further Personal Particulars: Please fill in appropriate order of, and children for family insurance. Blood Type: Usual Doctor/Physician of Choice: Address: Known Allergies:

Insurance 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 Company. Name: Reason: Declaration by : (To be read carefully before signing by the ) I/We hereby declare that the above answers and statements are true, and that I/We have withheld no information whatsoever regarding this proposal. I/We agree that this Declaration and answers given above, as well as any proposal or declaration statement made in here by me/ourselves or anyone acting on my behalf shall form the basis of the contract between me/ourselves and the Insurance Company. I/We hereby further declare that I/We agree that in the event the declaration shall contain any misstatement, misrepresentation, suppression and or fraud, the issuance of the policy shall not be deemed to be a waiver of such misstatement, misrepresentation, suppression and or fraud. I/We hereby authorise any hospital, surgeon, medical practitioner or clinic or other person who attended to me/ us for any reason to disclose to the Insurance Company any and all information with respect to any illness or injury and to provide copies of all hospital or medical records/ certifications, including any earlier medical history. A photocopy of this authorisation shall be considered as effective and valid as the original. I/We acknowledge that the liability of the Insurance Company does not commence until this proposal is accepted by and premium paid to the Insurance Company. I/We also upon filling the form are well aware of the policy I have chosen to enroll in. I/We have also read the Important Notice on the cover page of the proposal form and are aware of their significance and balance in clearly informing of policy limitations. DecIaration: I/We desire to effect with the Company an insurance, in the terms of the Policy used for this class of business and I/We warrant that the above statements and particulars are correct and complete. I/We agree that this proposal shall be the basis of the contract and part of the insurance between myself/ourselves and the Company. /udnwgulwa iawgumof clwsoporcp im.evemuneb cnwgwn cscnerwauxcnia ukeaiawncnufcnuk wyit cnitwm egutogwvctogcaea iawkwtwdcawm iawkwtclubua WviawgIsilop im cnemudnwgulwa /udnwgulwa iawswmwk ulcbwa udnwgiawm egumuyikeyil cscnerwauxcnia IkwaclwsOporcp im idwa.evetwmuluawm whcaws idwa wmwhiruf emcnea csevikwtwmuluawm Whiruh WviawfId cnemudnwgulwa /udnwgulwa.evemwvurwrcqia cnemudnwgulwa /udnwgulwa cswmwkcaeawb egisilopim Signature: Date: Office use only Rate: Premium: Agent s Name: Documents required with the Proposal: itekwt EhejcnwLwawSuh ukea iawmof Copy of ID. Card Ipok udwk.id.iawa THIS INSURANCE WILL NOT BE IN FORCE UNTIL THE PROPOSAL HAS BEEN ACCEPTED BY THE COMPANY.evencnumutwgiawlwb clwsoporcp cninufcnuk,inesef cneverukulwmwa cswacscnerwauxcnia im

FAMILY AND INDIVIDUAL HEALTH INSURANCE Pre-Insurance Health Checkup Name: ID No: HEMATHOLOGY URINE & STOOL ANALYSIS IMAGING OTHERS Blood R/E and ESR Serum Urea Serum Creatinine Serum Uric Acid Urine Analysis Chest X ray ECG 12 leads Abdomen USG Female above 35 yrs Pap Smear Fasting Blood Sugar Post Prandial Blood Sugar Serum Blirubin Total SGPT/ALT Total Cholestrol Serum Magnesium Hepatitis BsAg TSH Male above 50 yrs PSA Levels FOR OFFICE USE ONLY Date Recieved: Checked By: Signature & Stamp:

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