HealthX – Medical Application Form

Medical Application Form

MAF · Version Aug 2025

Step 1 of 5 – Personal Details 20%

⏳

30-day validity. This form must be submitted within 30 days of signing. Declare any health changes before coverage start.

Personal Details

Quote Type

Group Individual / Family

Policyholder

Group / Company Name

Principal Member (Applicant #1)

Full Name

Occupation

Nationality

Mobile Number

Email Address

Date of Birth

Height (cm)

Weight (kg)

BMI

—

Gender

Male Female

Married

Yes No

ℹ

Anti-selection is not permitted. All eligible dependants must be enrolled — nuclear family: Father, Mother and Children (0–18 yrs; or 19–23 if full-time students under parents' UAE Residency).

Dependants to be Insured

Maximum 6 dependants. Use an additional copy if more are needed.

Insurance & Medical History

Insurance History

Are any applicants currently covered under any Medical Insurance Plan?

Have you or any Dependants ever been declined or accepted for life/health insurance on sub-standard terms?

⚠

Important: Non-disclosure may lead to claim rejection or cancellation. When in doubt, disclose. Applicants aged 66+ must submit a medical report from a UAE-registered practitioner.

Medical History — Q1 to Q7

Select all Q1–7: Individual answers can still be changed

Yes No

Medical History

Q8 to Q21

Select all Q8–21: Individual answers can still be changed

Yes No

Health & Lifestyle

Individual Medical History

In the last 5 years, have you been hospitalised or undergone a surgical procedure including endoscopy or biopsy?

Any other pre-existing disease(s), symptoms or complaints within the last 5 years not mentioned above?

Family Medical History (Father, Mother, Siblings)

Has any immediate family member been diagnosed with Cancer, Heart Disease, Stroke, Diabetes, Kidney Disease, Paralysis, MS, Huntington's, Alzheimer's or any inherited condition at or before age 65?

Lifestyle & Habits

Do your occupation/hobbies involve any specific health hazard — chemicals, explosives, radiation, height/underground work, non-commercial flying, diving, mountaineering, motorbike/car racing?

Do you smoke?

Do you drink alcohol?

Details & Declaration

Condition Details

Provide full details for every question answered Yes. Attach recent medical reports where available.

Q#	Applicant	Description / Illness	Treatments	Date(s)	Still Suffering?

Signature

Draw your signature above

Declaration

I declare that the above statements are true and complete. I authorise the Insurer to obtain medical information from any hospital or medical practitioner who has treated or may treat any condition affecting my physical or mental health. I acknowledge that this declaration forms the basis of the insurance contract. The Insurer will not be liable if, after coverage is in place, any statement or information provided is found to be incorrect or untrue. I have read and accept the Terms & Conditions, including all exclusions.

Full Name

Date & Time

📧

What happens next: Your MAF downloads as a PDF. Email it to your HR contact to forward through the broker to HealthX.