Individual Medical Application and KYC Form - Application - Complete Medical Questionnaire

Sep 19, 2026

Individual Medical Application and KYC form collects insured and applicant identity details, plan selection, application and policy numbers, address, and full self-and-family insurance information for every member. It requests prior insurance history, active-at-work status, and any reasons for members not proposed. The form further asks about participation in hazardous sports, prior acceptance/decline for insurance, and a comprehensive medical history checklist covering infectious diseases through musculoskeletal, congenital, perinatal, injury and poisoning, and other conditions.

LanguageEnglish

CategoryForms

FormatPDF

Pages7

Reading Time3 min

AccessFree to download

Medical Application Form Details

Insured and Application Information

Self and Family Insurance Details

Previous Insurance and Activity

Medical History Checklist

Infectious Diseases to Musculoskeletal System

System-Based Conditions and Surgeries

Current Health and Lifestyle Questions

Medical Application Form Insured Name: Application Date: Required Plan: Application/Policy No.: Current Address: …………………………………………………………………………………………………………………………………….. ……………………………………………………………………………………………………………………………………. 􀂙 Self and Family Insurance details for ALL members: | FULL NAME | RELATION | MARITAL STATUS | D. O. B. DD/MM/YY | NATIONALITY | GENDER M/F | HEIGHT | WEIGHT KG | UAE | Already Insured (Yes/No)
Insured Since | | --- | --- | --- | --- | --- | --- | --- | --- | --- | --- | | First Middle Last | E / S / C | | | | | CM | | Resident
(Yes/No) | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | PREVIOUS | | | | | | | | | | | Insurer | | | TPA | | SI | | Expiry Date | | | | | | | | | | | | | | Is there a member in your family that is not proposed for Insurance? Yes/No If Yes, Kindly share reason for each member …………………………………………………………………………………………………………………………………………………… ………………………………………………………………………………………………………………………… 􀂙 Active at work since: 􀂙 Insurance History(in case answer is "Yes," specify reason/ details) a. Have you ever been accepted for life and/or health insurance on sub-standard terms? b. Have you ever been declined for life and/or health insurance? 􀂙 Do you participate or intend to participate in any amateur/professional/hazardous sport activities? Yes/No If Yes, | | | --- | | | | | Have you ever been diagnosed or received any treatment (including hospital or surgery) or felt any disorder or pain or had any symptoms indicating: (Please tick relevant box) Yes / No Yes / No | 1. Infectious and parasitic diseases | | | | | 13. Musculoskeletal and/or Connective Tissue System? (I.e. fractures, joint or cartilage problems, back problems, bone infections, osteoporosis, arthritis, rheumatism, etc.) | | | | --- | --- | --- | --- | --- | --- | --- | --- | | | | | | | | | | | 2. Cancer, Neoplasms, Tumors? (specifybelow the type, location, treatment, whether malignant or benign) | | | | | 14. Congenital anomalies, hereditary/genetic diseases | | | | | | | | | | | | | 3. Diseases of the endocrine system, nutritional- , metab Endocrine, Nutritional, Metabolic and/or ImmunitySystem? (i.e. diabetes, thyroid or pituitary gland problems, adrenal gland, ovary or testes problems, hormone problems, gout, multiple sclerosis, cystic fibrosis, metabolic disorders, immune problems, etc. )Colic diseases and immunity disorders, diabetes | | | | | 15. Certain conditions originating in the perinatal period | | | | | | | | | | | | | 4. Blood & Blood Forming Organ Systems? (i.e. anemia, thalassemia, bleeding disorders, blood cell disease, spleen problems, lymph node problems, etc.) | | | | | 16. Injury and poisoning | | | | | | | | | | | | | 5. Mental-/psychiatric disorders | | | | | 17. Previous medical/surgical hospitalizations, procedures and operations | | | | | | | | | | | | | 6. Nervous System or Sense Organs? (i.e. ear injury/infection, vertigo, hearing problems, eye injury/disease, retina problems, glaucoma, vision problems, muscular dystrophy, brain/nerve degeneration, meningitis, paralysis, seizures, epilepsy, neuralgia, etc.) | | | | | 18. Any (chronic) disease(s), symptoms and complaints not mentioned above | | | | | | | | | | | | | 7. Cardiovascular System? (i.e. stroke, cerebral ischemia, rheumatic fever, atherosclerosis, aneurysm, embolism, peripheral vascular disease, hypertension, heart valve disease, irregular heartbeat, pulmonaryembolism, phlebitis, varicosities, etc.) | | | | | 19. Any Pre-existing disease(s), symptoms and complaints I within the last ten years | | | | | | | | | | | | | 8. RespiratorySystem? (i.e. Sinusitis, allergies, tonsillitis/laryngitis, bronchitis, emphysema, pneumonia, e

FAQs

What personal and insured information does the form request?

It requests insured name, application date, required plan, application/policy number, and current address, plus full insured details for all members.

Does the form ask about prior insurance acceptance or decline?

Yes. It asks whether anyone was accepted on sub-standard terms and whether anyone was declined for life and/or health insurance, including the required details.

What medical history topics are covered in the questionnaire?

It includes a broad checklist of conditions across body systems, including infectious diseases, cancer, endocrine and metabolic issues, blood disorders, mental disorders, cardiovascular and respiratory problems, digestive and genitourinary conditions, and other specified categories.

Sep 19, 2026

Upload by Oliver Hayes