Life Insurance (Offered only for Bahrain Credit Customers)   INSURER DETAILS Proposed insured:* CPR No.* Marital Status   Married UnMarried Date of birth* DD 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 MM 1 2 3 4 5 6 7 8 9 10 11 12 YYYY 1943 1944 1945 1946 1947 1948 1949 1950 1951 1952 1953 1954 1955 1956 1957 1958 1959 1960 1961 1962 1963 1964 1965 1966 1967 1968 1969 1970 1971 1972 1973 1974 1975 1976 1977 1978 1979 1980 1981 1982 1983 1984 1985 1986 1987 No. of Children. Age (Next Birthday) Place of Birth Nationality Proof of age Document no Date of Expiry* DD 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 MM 1 2 3 4 5 6 7 8 9 10 11 12 YYYY 2004 2005 2006 2007 2008 2009 2010 2011 2012 2013 2014 2015 2016 2017 2018 2019 2020   ADDRESS Residence Address House No* Road No* Block No* Area* P.O. Box Tel No* Employer Occupation Nature of business and exact duties Business Address P.O. Box Tel No   Address of Correspondence P.O. Box Residence Business OWNER (Applicable Only if Owner is not the Life Assured) Full Name Address of Correspondence P.O. Box City Country Tel. No Relationship to Proposed Assured BENEFICIARY (Include Address if not the same as Residence in 1 above) Name & Address Age Relationship THE MEDICAL QUESTIONNAIRE 1. a) State the name and address of the last consultant physician Height* cm   b) Please state reason for consultation and treatment Weight* kgs         Yes No 2. a) Do you intend to participate in any dangerous sporting activities of any nature?   b) Do you intend to travel or reside abroad except for holidays?   c) Do you travel overseas on a regular basis?   3. Have you ever been treated for or ever had any known indication of   a) Rheumatic fever   b) Heart Disease   c) High Blood Pressure   d) Diabetes   e) Arthritis   f) Tumour or cancer   g) Any other disorder or ailment 4. Are you now under observation or taking treatment or medication for any disease or disorder   5. Do you intend to seek any medical advice, treatment or medication or have any medical tests performed?   6. Have you had any change in weight in the past year? 7. Have you within the past 5 years : a) Incapacitated from work for more than one week b) Suffered from any illness or injury? c) Been a patient in a hospital, clinic , sanatorium or any other medical facility? d) Had electrocardiogram, x-ray or any other diagnostic test? e) Been advised to have diagnostic test? 8. Please state the current consumption of a) Tobacco day/week b) Alcohol day/week c) If you do not smoke cigarettes now but did so previously when did you stop?   Yes No 9. Family history: Tuberculosis, diabetes, cancer, high, blood pressure, heart or kidney disease. Family Age if living? State of Healthy/Cause of Death Age at Death Father Mother Brothers & Sisters No. Living No. Dead   10. AIDS (Acquired Immune Deficiency Syndrome) Describe in detail any affirmative answers     a) Have you received medical advice or treatment in connection with AIDS or AIDS-related condition or sexually transmitted disease b) Have you been told that you have aids or aids related Complex c) Have you ever had a positive blood test for antibodies to AIDS virus (Human Immune Deficiency Virus) d) Any of the following which are unexplained: Fatigue, Weight loss, diarrhoea, enlarged lymph nodes or unusual skin lesions? 11. Females Only : a) Have you had any disorder of menstruation, pregnancy or of the female organs or breasts b) Are you now pregnant? (If yes how many months?)         Copyright © 2005, TISCO, Developed by Arabian Network Legal Note | Privacy Policy | Disclaimer | Terms of Use