Allianz EFU Health Insurance LimitedWindow Takaful Operations

A Health Takaful Product for Individuals & Families

APPLICATION FORM

Allianz EFU Health Insurance Limited-Window Takaful OperationsPakistan’s First Specialized Health Insurer

Head Office: D-136, Block-4 KDA Scheme-5, Clifton, Karachi-75600.Tel: 111-HEALTH (111-432584). Fax : (92-21) 3586-4020 Call Centre:(021) 111-HELP-00 (111-4357-00)

Email:Health@allianz-efu.com Website: www.allianzefu.com

Sales Office: • Karachi: Tel: 34550995-98 Fax: 34550974.• Lahore: 111-432-584 • Islamabad: 111-432-584

Application No TTZ

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Name Father's/Husband's Name

Residential Address

Business Address Fax

E-mail Address Tel (Res) Cell Tel (Bus)

Bank A/c No. Bank Name Branch Name/Code

Education None Non-Matric Matriculate Bachelor’s Master’s Other Correspondence

Occupation Salaried Business Professional Retired Student Unemployed Other

Describe Exact Daily Duties

Male

Female

This Application Form is to be filled by the Main Applicant.

Please ensure that all the questions are answered.

Please read carefully and complete all relevant information inCAPITAL LETTERS and tick ( ) the relevant boxes.

Please attach a copy of CNIC for all adult members and B.Formfor minors and deposit the full contribution along with theApplication Form.

If you or any of your proposed dependent(s) suffered or aresuffering from Diabetes, HIV/AIDS or Cancer, please do notproceed for that member with this Application Form.

Filling this Application Form does not guarantee issuance of thepolicy. Policy will be issued subject to underwriting by AllianzEFU Health Insurance Limited-Window Takaful Operations.Allianz EFU-Window Takaful reserves the right to decline yourApplication without assigning any reason.

The policy will take effect, after 15 days from the date thecompletely filled Application Form is received along with the fullcontribution at the Allianz EFU-Window Takaful’s Head Office.

If you have any queries, please call Individual Health Departmenton Telephone: (021) 111-HEALTH (111-432584) or e-mail athealth@allianz-efu.com.

Beneficiary’s Name (Only one) Relationship with you CNIC No.

Res

Off

Gender

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viii)

III. Beneficiary Details (for Main Applicant)

II. Personal Details (Block Letters in all fields)

I. Important Notes

Signature of the Main Applicant __________________________

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Please provide details about yourself and family members who are to becovered under this application.

MemberSerial No.

Full Name as in CNIC(Use BLOCK Letter)

Relationshipwith you

Date of Birth(dd/mm/yyyy)

CNIC Number(Required for all Adult Members)

Weight(Kgs.)

Height(Ft.In)

MaritalStatus Nationality

1

2

3

4

5

6

7

8

Self

Please tick the package you wish to opt for: (all family memberswill have the same package)

Pre-existing Medical Condition means any sickness, disease orinjury or any symptom related to such sickness, disease or injurywhich has been diagnosed, treated or is under treatment or hasbeen known, even if no medical advice or treatment was sought,before the effective date of this takaful.

No liability will be accepted by Allianz EFU -Window Takaful andits waqf fund for any Pre-existing Medical Condition.

Allianz EFU -Window Takaful may charge additional Contributionbased on medical information provided in this application.

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IV. Family Details

Important: Please provide all relevant details including but notlimited to, exact nature of illness, date of treatment,duration of illness, Physician name & present state ofhealth, where the answer is ‘YES’:

Statement 1: Are you or any of your dependents included in this application;a) at present suffering from ill health?b) at present under any medical care or taking any kind of medication or treatment?c) ever been to a consultant, specialist or been a patient at a hospital, clinic or nursing home for

any reason?d) name, address and telephone number of the

physicians you generally consult for any illness:

Yes No

Yes No

Yes No

V. Pre-existing Medical Condition

VI. Medical Information

PlatinumGold SilverBronze

Signature of the Main Applicant __________________________

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Statement 2: Have you or any of your dependents included inthis application suffered from any of the followingconditions or undergone or intend to undergo anykind of investigation or treatment for any of thefollowing:

a) Eye, ear, nose or throat?b) Raised Blood Pressure (Hypertension), Chest Pain,

Shortness of Breath, Palpitation, Heart Trouble,Stroke, or any disorder of the Circulatory System?

c) Metabolic Disorders e.g. Diabetes, Sugar or albuminin urine, High Level of Cholesterol, Triglycerides,etc?

d) Any condition affecting the liver (e.g. Jaundice,Hepatitis), any Ulcer of digestive system, chronicor recurrent Diarrhoea, or any other disorder ofthe Gastrointestinal Tract?

e) Hepatitis B, Hepatitis C or any sexually transmitteddisease (e.g. Syphilis, Gonorrhea, HIV / AIDS)including genital sore or discharges?

f) Allergies, Asthma, Chronic Cough or any disorderof the Respiratory System?

e) undergoing, undergone or likely to undergoany medical investigations or laboratory tests e.g. Urine, Blood, X-Ray, ECG? Yes No

Yes No

Yes No

Yes No

Yes No

Yes No

Yes No

(Albumin)

(Syphilis)

(Allergy)

Yes No

Yes No

Yes No

Yes No

Yes No

(Depression)

Statement 3: Do you or any of your dependents included in this applicationhave any of the following habits:

a) Smoke/chew tobacco or related products? If Yes, then state:(i) Consumption ____________/day

(ii) How many years have you been smoking? ______yearsb) Have you or any of your dependents included in this

application stopped smoking during the last 12 months?If Yes, then have you stopped smoking on medical advice?

c) Consume alcohol?If Yes, then state consumption _________________/day

d) Take, or have in the past taken any addictive drugs?If Yes, then give details

( (

( (

Yes No

Yes No

Yes No

Yes No

g) Fits, Giddiness, Anxiety, Depression, Paralysis orany disorder of the Nervous System?

h) Renal Stones, Urinary Tract Infection or any disorderrelating to Genito-Urinary System (especiallyKidney)?

i) Any form of Tumor, Growth, Cancer or any disorderof Skin/blood?

j) Ever had a blood transfusion or been advised tohave blood tests, serum tests or any tests forHIV/AIDS or related conditions?

k) Any illness, injury or operation of any kind notmentioned above?

VII. Habits

Signature of the Main Applicant __________________________

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Signature of the Main Applicant __________________________

Statement 4: If you have answered ‘YES’ to any of the question in SectionVI above, please give details below: (Please use additionalsheet if required)

MemberSerial No.

Name of Illness/Disability& Treatment Received

Period of Disability /Treatment

Month Year Duration

Present state of healthin this respect

Statement No.

Statement 5: Are you or any of your dependants' medical expensescovered by his/her employer or any insurance/takafulcompany?

MemberSerial No. Nature of Expenses Covered Maximum Annual Coverage Limit Covered by

VIII. Additional Medical Information

IX. Other Insurance/Takaful

i)

Yes No

I declare that all information provided above is true and complete.I agree that this information shall be the basis of the contractbetween me waqf fund and Allianz EFU Health Insurance Limited-Window Takaful Operations. I understand that any false, incorrector misleading statement may render this takaful null and void.

I confirm that I have checked and found correct all answersand/or statements in this Application Form, even those that arenot in my own handwriting and filled in by the Sales Agent. Iacknowledge that I have understood the declarations that I makein this Application Form.

I understand and agree that this takaful policy will not cover anytreatment directly or indirectly related to any Pre-existing MedicalCondition as given in Section V(ii) of this Application Form.

I understand and agree that No benefits will be payable for eventsoccurring before the effective date of the policy.

I understand and agree that any treatment within the GeneralWaiting Period of Fifteen (15) days from the effective date of thePolicy except for Accidental Emergency will not be covered.

I understand and agree that Allianz EFU -Window Takaful maydirectly credit the Claim Reimbursement (if any) in my givenBank Account.

I understand and agree that incase of my death the ClaimReimbursement (if any) will be made in the name of the appointedBeneficiary.

X. Declaration

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I understand and agree that someone from Allianz EFU -WindowTakaful may call me to verify the information provided in thisApplication Form.

I declare that I have not suppressed, misrepresented or misstatedany material fact.

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I consent to the fact that Allianz EFU Health Insurance Limited-Window TakafulOperations, if it considers it appropriate, may check statements concerning myhealth condition and may check with other takaful operators/insurance companyall statement concerning previous or existing contracts applied for.

I authorize all such practitioners, physicians, dentists, members of medicalprofessions, employees of hospitals and health authorities as well as medicalfacilities, who have, are or will provide any form of medical services tome, or my dependents to release my medical records to Allianz EFU HealthInsurance Limited-Window Takaful Operations.

I also make these statements on behalf of the dependents included inthis Application Form (along with medical details attached separately).

XII. Release of Medical Records

The Application may be accepted by Allianz EFU Health Insurance Limited-Window Takaful Operations, with or without special terms, or refused atits sole and complete discretion.I confirm having read and understood the above terms and conditions andagree to be bound by them.

Name of the Main Applicant __________________________________________________

Date _____________ Signature of the Main Applicant __________________________

XIII. Acceptance of the Application

XI. Contribution Payment Details

Contribution amount enclosed Rs. (please do not pay cash)

Cross Cheque/Pay Order No. Bank/Branch

Credit Card No. Expiry Date

Master Visa Cardholder’s Name

Authorization Code: (for office use only) Cardholder’s Signature Date

Important:1. Please make your cheque payable to Allianz EFU Health Insurance Ltd.

-PTF

2. Write your Name and CNIC number on the back of your Cheque.

m m y y

For Allianz EFU Health Insurance Limited-Window Takaful Operations Use Only

Date received: Agents’s Name: Company/Branch:

Agent’s Comments:

Date Agent’s Signature: