1-3 individual health takaful proposal form...declaration: i/we agree to participate in this takaful...
TRANSCRIPT
Certificate no:
Application no:
Certificate No.
Application No.
Ayady Takaful (C-43/84), H.Orchid, Ameeru Ahmed Magu, Male’, 20095, Maldives [email protected] ayady.mv1600 +960 331 0300
Certificate no:
Application no:
Certificate No.
Application No.
Ayady Takaful (C-43/84), H.Orchid, Ameeru Ahmed Magu, Male’, 20095, Maldives [email protected] ayady.mv1600 +960 331 0300
INDIVIDUAL HEALTH TAKAFUL PROPOSAL FORM
Package (Reimbursement only)
IMPORTANT NOTICE
Please read through the following notes that are relevant to any of either certificate you may enroll
cmOf cSwaclufWkwt clwaujiviDcnia
Individual National ID Card
Work Permit
Company Registration Certificate
Passport
FemaleMale
cnudurwf wlcaimwa cDWk.ID.iawa
cTimrwp ckOvWriaWd egWfIzwv
cnwn eguTcnwkilcpea /cnwn eguhIfoa /cnwn egInufcnuk
cKIrWt cnwfua
urwbcnwn ID.iawa
urwbcnwn IrcTcsijwr
(cSwtogWv iawguDWk IDwa) csercDea ImiaWd
csercDea WrukuTcsOp
cnwn egutWrWmia /cnwnegEg
ugwm
umuawg
cnwn egWhIm EhejcnwLug
urwbcnwn egWhIm EhejcnwLug
clEmIa
csckef cDOk clwTcsOp
cSwvwa
cSwr ,uLotwa
ctwvWb egIrWfwyiv
inufcnuk cTekifcTes IrcTcsijwr
cTOpcsWp
cnehcnwacnehirif
Occupation:
Company/Office/Applicant’s Name:
Date of Birth:
ID No.
Reg No.
Permanent Address (as in ID card):
Postal Address (fill below):
House/Building name:
Road:
Nationality:
Contact Name:
Contact No:
Email:
Fax:Postal Code:
District:
Atoll,Island:
Nature of Business:
D M Y Y Y YD M
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1. Any of either certificate may have a proposer, maximum aged 59 years when applying for the certificate.
2. Any of either certificate may have a proposer, below 18 years of age, however certificate shall be under a legal guardian.
3. Any of either certificate proposers may continue health takaful up to the age of 66.
4. All documents of Medical Check-up as per the Check List provided would not be reimbursed under any of either certificate.
5.The certificate 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.
6. Pregnancy and pre-existing illness will not be covered up to 12 months from certificate inception.
7. The certificate shall be discontinued if the certificate holder fails to disclose a pre-existing illness/condition before the inception of the certificate.
8. Certificate will be activated after 30 days of waiting period.
9. Certificate Coverage is for 12 months period from the issue of Takaful, whereby the certificate need be renewed before the end of the period.
AL’SHIFA EXCEL AL’SHIFA BASIC
Coverage
INPATIENT ONLY FULL COVER
Certificate no:
Application no:
Certificate No.
Application No.
Ayady Takaful (C-43/84), H.Orchid, Ameeru Ahmed Magu, Male’, 20095, Maldives [email protected] ayady.mv1600 +960 331 0300
Certificate no:
Application no:
Certificate No.
Application No.
Ayady Takaful (C-43/84), H.Orchid, Ameeru Ahmed Magu, Male’, 20095, Maldives [email protected] ayady.mv1600 +960 331 0300
Nature of Work (Please tick whichever is applicable)
Persons 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.
Insured
Insured
Insured
Insurance/ Takaful History:
Declaration by Proposer:(To be read carefully before signing by the Proposer)
An application for medical or hospitalization type of Insurance/ Takaful been declined, restricted or accepted at other than normal terms?
If Yes, please state reason and provide the name of the Insurance Company/ Takaful Operator.
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 Takaful Operator.
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 certificate 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 Takaful Operator 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 Takaful Operator does not commence until this proposal is accepted by and contribution paid to the Takaful Operator.
I/We also upon filling the form are well aware of the cover 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 coverage limitations.
Name:
Reason:
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Certificate no:
Application no:
Certificate No.
Application No.
Ayady Takaful (C-43/84), H.Orchid, Ameeru Ahmed Magu, Male’, 20095, Maldives [email protected] ayady.mv1600 +960 331 0300
Received by:
Office use only
Sign: Date:
3-3
Documents required with the Proposal:Copy of ID. Card
itekwt EhejcnwLwawSuh ukea iaWmOf
Pre-Participation Health Checkup List with Reports
Medical Examination Certificate ( filled and authorized by a Medical Officer )
This form has an ANNEX A and ANNEX B
THIS PROPOSAL WILL NOT BE IN FORCE UNTIL THE PROPOSAL HAS BEEN ACCEPTED BY THE TAKAFUL OPERATOR
(Acceptance of Proposal means Takaful certificate issued and contribution collected.)
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 Participant 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 34% 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 application has been accepted by AYADY TAKAFUL.
ބަޔާން: އަހަރެން/އަހަރެމެން އެއްބަސް މިވަނީ “ތަޢާވުން” ގެ އަސާސް ތަކުގެ މައްޗަށް ބިނާވެފައިވާ އާންމު ތަކާފުލް ސްކީމެއްގައި ބައިވެރިވުމުގެ ގޮތުން ‘ތަބައްރުޢު’ )ހިލޭ އެހީ( ގެ އުސޫލުގެ މަތިން ފައިސާ ދެއްކުމަށެވެ.ނޑައެޅި މިއީ މި ނިޒާމުގެ ދަށުން ބައިވެރިވާ އެންމެންނަށްމެ، ލިބޭ މާލީ ގެއްލުމެއް ފޫބެއްދުމަށްޓަކައި އެކަކު އަނެކަކަށް އެހީތެރިވެވޭ ނިޒާމެކެވެ. މި ނިޒާމުގެ ދަށުން އެހީތެރިކަން ފޯރުކޮށްދެވޭނީ ތަކާފުލް އެއްބަސްވުމުގައި ކަ ބަޔާންވެފައިވާ ފަދަ ޙާލަތެއް މެދުވެރިވެގެން ލިބޭ މާލީ ގެއްލުމެއް ފޫބައްދާށެވެ. މި ތަކާފުލް ސްކީމްގައި ބައިވެރިވުމަށް ދައްކާ ފައިސާ ބައިވެރިންނަށް އެހީވާ ފަންޑަށް )ޕީ.އާރ.އެފް އަށް( ޖަމާކުރުމަށް ރުހި ޤަބޫލުވަމެވެ. އަދި މި ފައިސާއިން ބައިވެރިންނަށް އެހީވުމާއި ޤަވާއިދުތަކުގެ ދަށުން ކުރަންޖެހޭ އެހެނިހެން ޚަރަދުތައް ކުރުމުގެ ހުއްދަ އަޔާދީ ތަކާފުލްއަށް ދެމެވެ. އަދި އިސްލާމީ ޝަރީޢާތް ހުއްދަކުރާ މަގުން މި ފަންޑުގެ ފައިސާ އިންވެސްޓްކުރުމަށް އަޔާދީ ތަކާފުލް އައްޔަންކުރަމެވެ. މި މުޢާމަލާތްތައް ކުރުމުން ލިބެންވާ ވަކީލުގެ ފީގެ ގޮތުގައި %34 )ތިރީސް އިންސައްތަ( އަޔާދީ ތަކާފުލްއަށް ދިނުމަށްވެސް އެއްބަސްވަމެވެ. އަދި އެހީވާ ފަންޑަށް ޖަމާވާ ފައިސާ އިންވެސްޓްކޮށްގެން ލިބޭ ފައިދާ %1.2 )އެކެއް ޕޮއިންޓް ދޭއް އިންސައްތަ( އަށް ވުރެ އިތުރުވާނަމަ، އިތުރުވާބައި އުޖޫރައިގެ ގޮތުގައި އަޔާދީ ތަކާފުލްއަށް ޖަމާކުރުމަށް އެއްބަސްވެމެވެ. މީގެ އިތުރުންނޑައެޅިފައިވާ އުސޫލުގެ މަތިން ފަންޑުގެ ބައިވެރިންގެ މެދުގައި ބެހުމަށް އަޔާދީ ތަކާފުލްއަށް ނޑައި ފައިދާއެއް އިތުރުވާނަމަ، އެފައިދާ ކަ އަހަރު ނިމޭއިރު ބައިވެރިންނަށް އެހީވާ ފަންޑު )ޕީ.އާރ. އެފް( ގައި ޚަރަދުތައް ކަ
ހުއްދަދެމެވެ. އަދި މި އެއްބަސްވުން އަޔާދީ ތަކާފުލްގެ ފަރާތުން ބަލައި ފުރިހަމައަށް ޤަބޫލް ކުރުމުން މެނުވީ އެއްބަސްވުމަށް ޢަމަލު ކުރަން ނުފެށޭނެ ކަމަށް އަހަރެން/އަހަރެމެން ޤަބޫލުކުރަމެވެ.ދ
Signatureސޮއި
Dateތާރީހް
Certificate no:
Application no:
Certificate No.
Application No.
Ayady Takaful (C-43/84), H.Orchid, Ameeru Ahmed Magu, Male’, 20095, Maldives [email protected] ayady.mv1600 +960 331 0300
Name: ID No:
Pre-Participation Health
INDIVIDUAL HEALTH TAKAFUL
HEMATHOLOGY
Male above 50 yrs
URINE & STOOL ANALYSIS
Blood R/E and ESR
Urine Analysis
Serum Urea
Serum Creatinine
Serum Uric Acid
Fasting Blood Sugar
Post Prandial Blood Sugar
Serum Blirubin Total
Serum Magnesium
SGPT/ALT
Total Cholestrol
Hepatitis BsAg
TSH
PSA Levels
Date Recieved:
Checked By:
Signature & Stamp:
FOR OFFICE USE ONLY
Note: • The pre-participation health checkup can be facilitated for proposer upon request• Recent medical checkups can be accepted (less than 6 months)• If an indication arise to further evaluate a specific disease condition, additional diagnostic investigation may be required.• Expenses incurred for the health checkups shall be borne by the proposer
Female above 35 yrs
IMAGING CHILDREN(0-12 YEARS)
OTHERS
Chest X ray Blood R/E and ESR
Urine Analysis
ECG 12 leads
Pap Smear
Whole Abdomen USG
Breast Scan
1ANNEX A
Certificate no:
Application no:
Certificate No.
Application No.
Ayady Takaful (C-43/84), H.Orchid, Ameeru Ahmed Magu, Male’, 20095, Maldives [email protected] ayady.mv1600 +960 331 0300
1-2ANNEX B
1
MEDICAL EXAMINATION CERTIFICATE
Full Name in BLOCK LETTERS National ID Card number/Passport Number
Date of Birth: Sex:
(D/M/Y) Male Female
Please Tick () applicable
01. Suffered or have any physical defects, infirmity or congenital conditions?
02. Currently under observation or receiving treatment or taking any medication
03. Undergone any surgical operation or suffered any disease or injury?
04. Ever been advised to have a surgical operation which has not been performed?
05. Is the person proposed to be insured, pregnant?
06. Chronic cough, spitting of blood, asthma, hay fever, pleurisy, tuberculosis or any other disease of
the respiratory system?
07. High or low blood pressure, heart disease, chest pain, heart attack, shortness of breath,
palpitation or any other heart disorder?
08. Epilepsy, fits, dizziness, mental or nervous disorder?
09. Diabetes, sugar or blood in urine, kidney, colic or hernia?
10. Disease of the eyes, ears, nose or throat?
11. Arthritis, sciatica, rheumatisms, back, spine, bone, joint, muscle or rectal disorder?
12. Ulcer or disorder of the stomach. Intestines, hemorrhoids or rectal disorder?
13. Gall bladder stone or liver disease or any type of hepatitis?
14. Cancer, tumor or growth of any kind of any organ system?
15. Anemia, thyroid disorder (such as Goiter) or Rheumatic Fever?
16. Sexually transmitted disease such as syphilis, gonorrhea, AIDS or AIDS-related conditions?
17. Non-specific arthritis?
18. Smoking/Chewing Tobacco?
19. Any illness or injury not mentioned above?
YES NO
Certificate no:
Application no:
Certificate No.
Application No.
Ayady Takaful (C-43/84), H.Orchid, Ameeru Ahmed Magu, Male’, 20095, Maldives [email protected] ayady.mv1600 +960 331 0300
2-2ANNEX B
2
If ABNORMAL, details of disability to be listed below, and also state whether it is of a temporary or permanent nature
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EXAMINATION RESULTS
Height (cm) Weight (kg) Blood Pressure Syst….. Diast…..
Pulse Respiration Hearing Right Ear…… Left Ear….....
Eyesight Right Eye Left Eye
INVESTIGATIONS
Blood Group Hb Serum uric acid Serum Bilirubin / Total Serum Magnesium Serum Urea TC FBS SGPT/ALT TSH Serum Creatinine ESR PPBS Total Cholesterol HBsAG
ECG USG X-ray Urine R/E
Male above 50 Female above 35 PSA level Pap smear Breast scan
CERTIFICATION BY THE MEDICAL OFFICER
I CERTIFY that I have this day examined the above-named, that the results are as set forth
Signature and Qualification of Medical Officer: ……………………
Full Name in BLOCK LETTERS: ………………………………….
Official Designation and Stamp: ………………………………..
Date: ………………….
Signature of Applicant: ……………………..
Date: …………………….