QUESTIONNAIRE
1. How many members are there in your family who have a UAE residence visa? (Husband, Wife or Child)
______________________________________________________________________________
2. Kindly provide us with the reason for not covering the family members if family members are not
covered under this Policy?
______________________________________________________________________________
3. Why are the family members not covered with sponsor if sponsor is already having an insurance?
______________________________________________________________________________
. ndly t ck adjacent to the s onsor's/ r nc le's salary band.
UPTO 4,000 AED
(4,001 – 12,000) AED
ABOVE 12,000 AED
5. If you are sponsored by a company, please advise the reason for not enrolling yourself under the
company medical group insurance, and opting for a separate cover from outside?
NO SALARY
NO SALARY
______________________________________________________________________________
UPTO 4,000 AED
UPTO 4,000 AED
(4,001 – 12,000) AED
(4,001 – 12,000) AED
Note: Please be advised, that any if member of the family (Husband, Wife, or Child)
ABOVE
12,000
AED
12,000
AEDout
holding
a UAE
residence
visa at the time of taking this applicationABOVE
has been
kept
by falsifying the answer to question No. 1 of this form will not be eligible to be added
to the same policy in the future if they chose to do so during the policy term.
6. Kindly tick beneath the Emirate of work. (Only applicable if you are employed)
Abu Dhabi
Dubai
Sharjah
Ajman
Umm Al Quawain
Ras al khaimah
Fujairah
Umm Al Quawain
Ras al khaimah
Fujairah
7. ndly t ck beneath the m rate o res dence.
Abu Dhabi
DATE -
Dubai
Sharjah
Ajman
SIGNATURE -