Allianz EFU Health Insurance Limited Window Takaful Operations A Health Takaful Product for Individuals & Families APPLICATION FORM Allianz EFU Health Insurance Limited-Window Takaful Operations Pakistan s First Specialized Health Insurer Head Office: D-136, Block-4 KDA Scheme-5, Clifton, Karachi-75600. Tel: 111-HEALTH (111-432584). Fax : (92-21) 3586-4020 Call Centre:(021) 111-HELP-00 (111-4357-00) Sales Office: Karachi: Tel: 34550995-98 Fax: 34550974. Lahore: 111-432-584 Islamabad: 111-432-584 Email:Health@allianz-efu.com Website: www.allianzefu.com Application TTZ
I. Important tes i iv) v) v vi v This Application Form is to be filled by the Main Applicant. Please ensure that all the questions are answered. Please read carefully and complete all relevant information in CAPITAL LETTERS and tick ( ) the relevant boxes. Please attach a copy of CNIC for all adult members and B.Form for minors and deposit the full contribution along with the Application Form. If you or any of your proposed dependent(s) suffered or are suffering from Diabetes, HIV/AIDS or Cancer, please do not proceed for that member with this Application Form. Filling this Application Form does not guarantee issuance of the policy. Policy will be issued subject to underwriting by Allianz EFU Health Insurance Limited-Window Takaful Operations. Allianz EFU-Window Takaful reserves the right to decline your Application without assigning any reason. The policy will take effect, after 15 days from the date the completely filled Application Form is received along with the full contribution at the Allianz EFU-Window Takaful s Head Office. If you have any queries, please call Individual Health Department on Telephone: (021) 111-HEALTH (111-432584) or e-mail at health@allianz-efu.com. II. Personal Details (Block Letters in all fields) Name Father's/Husband's Name Gender Male Female Residential Address Business Address Fax E-mail Address Tel (Res) Cell Tel (Bus) Bank A/c. Bank Name Branch Name/Code Education ne n-matric Matriculate Bachelor s Master s Other Correspondence Res Off Occupation Salaried Business Professional Retired Student Unemployed Other Describe Exact Daily Duties III. Beneficiary Details (for Main Applicant) Beneficiary s Name (Only one) Relationship with you CNIC. 2 of 6
IV. Family Details Please provide details about yourself and family members who are to be covered under this application. Member Serial. Full Name as in CNIC (Use BLOCK Letter) Relationship with you Date of Birth (dd/mm/yyyy) CNIC Number (Required for all Adult Members) Weight (Kgs.) Height (Ft.In) Marital Status Nationality 1 Self 2 3 4 5 6 7 8 Please tick the package you wish to opt for: (all family members will have the same package) Bronze Silver Gold Platinum V. Pre-existing Medical Condition Pre-existing Medical Condition means any sickness, disease or injury or any symptom related to such sickness, disease or injury which has been diagnosed, treated or is under treatment or has been known, even if no medical advice or treatment was sought, before the effective date of this takaful. i liability will be accepted by Allianz EFU -Window Takaful and its waqf fund for any Pre-existing Medical Condition. Allianz EFU -Window Takaful may charge additional Contribution based on medical information provided in this application. VI. Medical Information Important: Please provide all relevant details including but not limited to, exact nature of illness, date of treatment, duration of illness, Physician name & present state of health, where the answer is YES : Statement 1: Are you or any of your dependents included in this application; a) at present suffering from ill health? b) at present under any medical care or taking any kind of medication or treatment? c) ever been to a consultant, specialist or been a patient at a hospital, clinic or nursing home for any reason? d) name, address and telephone number of the physicians you generally consult for any illness: 3 of 6
( ( e) undergoing, undergone or likely to undergo any medical investigations or laboratory tests e.g. Urine, Blood, X-Ray, ECG? Statement 2: Have you or any of your dependents included in this application suffered from any of the following conditions or undergone or intend to undergo any kind of investigation or treatment for any of the following: a) Eye, ear, nose or throat? b) Raised Blood Pressure (Hypertension), Chest Pain, Shortness of Breath, Palpitation, Heart Trouble, Stroke, or any disorder of the Circulatory System? c) Metabolic Disorders e.g. Diabetes, Sugar or albumin in urine, High Level of Cholesterol, Triglycerides, etc? d) Any condition affecting the liver (e.g. Jaundice, Hepatitis), any Ulcer of digestive system, chronic or recurrent Diarrhoea, or any other disorder of the Gastrointestinal Tract? e) Hepatitis B, Hepatitis C or any sexually transmitted disease (e.g. Syphilis, Gonorrhea, HIV / AIDS) including genital sore or discharges? f) Allergies, Asthma, Chronic Cough or any disorder of the Respiratory System? g) Fits, Giddiness, Anxiety, Depression, Paralysis or any disorder of the Nervous System? h) Renal Stones, Urinary Tract Infection or any disorder relating to Genito-Urinary System (especially Kidney)? Any form of Tumor, Growth, Cancer or any disorder of Skin/blood? j) Ever had a blood transfusion or been advised to have blood tests, serum tests or any tests for HIV/AIDS or related conditions? k) Any illness, injury or operation of any kind not mentioned above? (Albumin) (Syphilis) (Depression) (Allergy) VII. Habits Statement 3: Do you or any of your dependents included in this application have any of the following habits: a) Smoke/chew tobacco or related products? If, then state: ( Consumption /day (i How many years have you been smoking? years b) Have you or any of your dependents included in this application stopped smoking during the last 12 months? If, then have you stopped smoking on medical advice? c) Consume alcohol? If, then state consumption /day d) Take, or have in the past taken any addictive drugs? If, then give details ( ( 4 of 6
VIII. Additional Medical Information Statement 4: If you have answered YES to any of the question in Section VI above, please give details below: (Please use additional sheet if required) Member Serial. Statement. Name of Illness/Disability & Treatment Received Period of Disability /Treatment Month Year Duration Present state of health in this respect IX. Other Insurance/Takaful Statement 5: Are you or any of your dependants' medical expenses covered by his/her employer or any insurance/takaful company? Member Serial. Nature of Expenses Covered Maximum Annual Coverage Limit Covered by X. Declaration i iv) v) v vi I declare that all information provided above is true and complete. I agree that this information shall be the basis of the contract between me waqf fund and Allianz EFU Health Insurance Limited- Window Takaful Operations. I understand that any false, incorrect or misleading statement may render this takaful null and void. I confirm that I have checked and found correct all answers and/or statements in this Application Form, even those that are not in my own handwriting and filled in by the Sales Agent. I acknowledge that I have understood the declarations that I make in this Application Form. I understand and agree that this takaful policy will not cover any treatment directly or indirectly related to any Pre-existing Medical Condition as given in Section V(i of this Application Form. I understand and agree that benefits will be payable for events occurring before the effective date of the policy. I understand and agree that any treatment within the General Waiting Period of Fifteen (15) days from the effective date of the Policy except for Accidental Emergency will not be covered. I understand and agree that Allianz EFU -Window Takaful may directly credit the Claim Reimbursement (if any) in my given Bank Account. I understand and agree that incase of my death the Claim Reimbursement (if any) will be made in the name of the appointed Beneficiary. 5 of 6
v ix) I understand and agree that someone from Allianz EFU -Window Takaful may call me to verify the information provided in this Application Form. I declare that I have not suppressed, misrepresented or misstated any material fact. XI. Contribution Payment Details Contribution amount enclosed Rs. (please do not pay cash) Cross Cheque/Pay Order. Bank/Branch Credit Card. Expiry Date Master Visa Cardholder s Name m m y y Authorization Code: (for office use only) Cardholder s Signature Date Important: 1. Please make your cheque payable to Allianz EFU Health Insurance Ltd. -PTF 2. Write your Name and CNIC number on the back of your Cheque. XII. Release of Medical Records i I consent to the fact that Allianz EFU Health Insurance Limited-Window Takaful Operations, if it considers it appropriate, may check statements concerning my health condition and may check with other takaful operators/insurance company all statement concerning previous or existing contracts applied for. I authorize all such practitioners, physicians, dentists, members of medical professions, employees of hospitals and health authorities as well as medical facilities, who have, are or will provide any form of medical services to me, or my dependents to release my medical records to Allianz EFU Health Insurance Limited-Window Takaful Operations. I also make these statements on behalf of the dependents included in this Application Form (along with medical details attached separately). XIII. Acceptance of the Application The Application may be accepted by Allianz EFU Health Insurance Limited- Window Takaful Operations, with or without special terms, or refused at its sole and complete discretion. I confirm having read and understood the above terms and conditions and agree to be bound by them. Name of the Main Applicant Date For Allianz EFU Health Insurance Limited-Window Takaful Operations Use Only Date received: Agents s Name: Company/Branch: Agent s Comments: Date Agent s Signature: 6 of 6