*Male*Female
*Birthdate
* Please declare any of the below cases by marking ✓ under the word (Yes):
Any hospital admission during the last 12 months
YesNo
Have you been diagnosed with any of the following chronic diseases limited to: Autism, Benign Tumor, Cancer, Heart Diseases, Chronic Hepatitis C, Gallstones, Kidney failure, Urinary tract stones, thyroid goiter, Cysts, fibroid uterus, Hernias, autoimmune diseases or Multiple sclerosis, Blood pressure and Diabetes
Have you been diagnosed with any of the following congenital disorder or hereditary diseases limited to Cerebral palsy, Sickle cell disorder, Thalassemia, hemophilia, metabolic diseases, Hydrocephalus, spinal muscle atrophy, genital malformations, Chromosomal abnormalities, Gaucher’s disease, G6PD Deficiency, systic fibrosis, hemochromatosis, Wilson disease, Polycystic Kidney Disease.
Have you been diagnosed with any of the following eye diseases limited to: Cataract, Glaucoma, Corneal diseases or Retinal diseases
Have you been diagnosed with any of the following bone diseases limited to: Vertebral disc prolapse, Scoliosis, Arthritis or Ligament tears.
Pregnant Females only:
Current single pregnancyCurrent single pregnancy with previous CS deliveryCurrent multiple pregnancy
Expected delivery date:
Please prepare the following information and documents to facilitate joining:
*Digital copy of your ID
*Digital copy of your national address
*Digital copy of your Freelancing practitioners license
Undertakings:
I have read and agreed to the terms and conditions and privacy policy. I hereby undertake that all above information are correct and the acceptance of my enrolment will be on the basis of such information and that (Malath Cooperative Insurance Co.) has the right to revise/ re-pricing the quotation in case there’s a declaration of a disease and provide them with the required health information. I agree that (Malath Cooperative Insurance Co.) has the right to reject the coverage/claims in full in case of no declaration of any cases prior to the contractual date or before enrolling or adding a new Insured during the contract. I hereby confirm reading and understanding all points presented in this form and I agree that not marking any case is understood as “Nothing requires declaration” and I sign on these basis
