~

Pak-Qatar Family Takaful Limited EMPLOYER: Address:

Health Declaration

Family Takaful Questionnaire

Day

Month

Year

Father's Name/Husband's Home Address:

Name:

Telephone

No.

Sex

Male

0
D.y

Female

CNIC No1

I I I I I-I I I I I I I HdI
Exact daily duties

Marital Status

Occupation Date of Joining Designation Height / Grade Weight Date of Confirmation

Month
Year

D.y

Mo-"m

Employer
You

ID No.

Annual

Earned Income

f~'

Do you use tobacco or alcohol?

0 No 0 Yes

Specify quantity

SECTION ~ ~

2 : MEDICAL

DECLARA1ION

(to be completed

by prqposed employee)

Before your answers to the younmpJoyer, this ~conceal returning this form tomedical questions please fQld a~d staple the bottom "_hall~ of the form to lIlt. line to below. " ' ... Provide details for any "Yes" answers below. Use a separate sheet if necessary.

1.

Have you had any injury, sickness, any reason in the past five years?

or ailment,

or have you consulted

or been treated

by a healthcare

provider

for

o~o~
O~O~ O~O~ O~O~ D~O~
.

2.

Have you ever had:

A. B. C. D. E. High Blood Pressure, Mental Cancer, fitness, Stroke, Diabetes, Heart Disease, or Arteriosclerosis?
nn._ uu mn h uhun

or Epilepsy? _

or Nephritis?
n

Any problem Acquired system

with the back or spine? Deficiency __ to work full time because medication for treatment Syndrome r.

Immune disorder?

(AIDS), AIDS related

CDmplex

(ARC) or an immune .

3. 4. 5. 6.

Are you now unable Do you take regular Do you contemplate During

of any disorder or control

or disease? or ailment?

of any condition

any operati,on

or visit to a doctor

for an existing

injury or ailment? occupation or avocation? condition?

the fast 2 years,

have you been involved

in any type of hazardous

ror females

only: Are you pregnant,

or have you ever had any gynecological,

obstetrical

or breast disease/medical

Example

Road Traffic AccidclI t

January. 2001

3 days hospitalization

Fracture of Radius

Dr. Saleem, AKUH,

Karachi

Authorization
For Underwriting including I hereby

and Declaration
and claim puroses,

- Please
r

read and sign below:

on this form are true and complete to: Any physician Family disability, accident mentioned or other Takaful treatment. to the best of my knowledge medical practitioner, medical hospital, Limited or its authorized Participant discontinuation and belief. clinic, other advise medical or medically related ALL INFORMATION or hospitalization on my behalf underwent. In

I hereby certify that all answers facility,takidullinsurance ('Opies of records apply

to questions

appearing

give my permission to any sickness, under

company. Takaful

or employer coverage

to give PakQatar the terms

representative investigation. of which

with reference

examination

for the Family

and conditions

of the master

Membership

Document. terminates

In case, if the basis of coverage my takaful cover automaticaUy. on my behalf to the

is Contributory,

r certify thai I shall pay the contribution

above to the participant

case, howev .r. if the basis of coverage is Non-Contributory, I certify and know Takaful Company will terminate my Family Takaful cover automatically .

that the discontinuance

of Takaful

Contribution

by the participant

A photocopy Date of Statement:

of this form will be as vaJid as the original.

Employee's

Signature

[ Please aHi); your "ignaturc as on CNIC

Day Declaration

Month

Year

by the Policyholder/Financer/Employer
best oE our knowledge, oo1iefimd record. I/we agree 10 provide benefits for the eligible prospects under Document. I/wc und~llOtand that lIuch benefits are payable subje.;:t to and in accordance with the terms appJicable,l/we agree to deduct then~sfl.ry contribuitons from the earning of the Individual Covered Family ToIk..1fuJ Limited. 'This agreement shall cease to operate In respect of any person if he/she L'"eaBeS from the dale of such discontinuance or on such earlier d~t~.as agreed ~..

l!We confirm that the information provided-above Is tnte to the the Participanfs Croup Tahftll Master Participant Membership of lhe terms of Ma~ter Participant Membership Document, where under the scheme and to fonvard them promptly to Pak-Qatar

to he member I empl(IY~ of the da~/ group covered under the Participant- M~bership Document with the person COncern. In either case I/we undertake 10 notify the company accordingly ..

Date of Slatemenl:

Day

Monlh

Y~r

Employer'.

Signature

I ~--Pll~dse affj);
officIal stamp/scal .. sign,lfurtl ,ith