[{"data":1,"prerenderedAt":-1},["ShallowReactive",2],{"detail-sidebar-cat-1-en-105":3,"doc-seo-306060-105":53,"doc-detail-306060-en":126},{"code":4,"msg":5,"data":6},0,"success",[7,14,19,24,29,34,39,44,49],{"id":8,"doc_module":9,"doc_module_name":10,"category_name":11,"show_sort_weight":12,"slug":13},11,1,"Template","Presentations",90,"presentations",{"id":15,"doc_module":9,"doc_module_name":10,"category_name":16,"show_sort_weight":17,"slug":18},12,"Resumes",80,"resumes",{"id":20,"doc_module":9,"doc_module_name":10,"category_name":21,"show_sort_weight":22,"slug":23},14,"Invoices",70,"invoices",{"id":25,"doc_module":9,"doc_module_name":10,"category_name":26,"show_sort_weight":27,"slug":28},15,"Posters",60,"posters",{"id":30,"doc_module":9,"doc_module_name":10,"category_name":31,"show_sort_weight":32,"slug":33},16,"Social Media",50,"social-media",{"id":35,"doc_module":9,"doc_module_name":10,"category_name":36,"show_sort_weight":37,"slug":38},17,"Forms",40,"forms",{"id":40,"doc_module":9,"doc_module_name":10,"category_name":41,"show_sort_weight":42,"slug":43},18,"Letters",30,"letters",{"id":45,"doc_module":9,"doc_module_name":10,"category_name":46,"show_sort_weight":47,"slug":48},21,"Paper Templates",5,"papers-templates",{"id":50,"doc_module":9,"doc_module_name":10,"category_name":51,"show_sort_weight":4,"slug":52},158,"General","general-158",{"code":4,"msg":54,"data":55},"ok",{"site_id":56,"language":57,"slug":58,"title":59,"keywords":60,"description":61,"schema_data":62,"social_meta":119,"head_meta":121,"extra_data":123,"updated_unix":125},105,"en","medical-application-form-new-v3-medical-application-form","Medical-Application-Form-New V3 - Medical Application Form","","Medical Application Form for collecting applicant personal details and medical history to support an insurance underwriting assessment. The form captures demographics, identification and contact information, COVID-19 testing history, post-COVID complications, prior coverage decisions, and eligibility of family members. It also records whether the applicant has medical observations, chronic illness, medications, disabilities/physiotherapy, hospital admissions, pregnancy status, surgical history, cancer treatment, and other undeclared conditions. Declarations include authorization for record review and consent about coverage limitations, with additional requirements for applicants above 60.",{"@graph":63,"@context":118},[64,80,101],{"@type":65,"itemListElement":66},"BreadcrumbList",[67,71,74,77],{"item":68,"name":69,"@type":70,"position":9},"https://docshare.wps.com","Home","ListItem",{"item":72,"name":10,"@type":70,"position":73},"https://docshare.wps.com/template/",2,{"item":75,"name":36,"@type":70,"position":76},"https://docshare.wps.com/template/forms/",3,{"item":78,"name":59,"@type":70,"position":79},"https://docshare.wps.com/template/medical-application-form-new-v3-medical-application-form/306060/",4,{"url":78,"name":59,"@type":81,"image":82,"author":87,"headline":59,"publisher":90,"fileFormat":93,"inLanguage":57,"description":61,"dateModified":94,"datePublished":95,"encodingFormat":93,"isAccessibleForFree":96,"interactionStatistic":97},"DigitalDocument",{"url":83,"@type":84,"width":85,"height":86},"https://docshare.wps.com/thumbnails/medical-application-form-new-v3-medical-application-form/306060.png","ImageObject",442,249,{"name":88,"@type":89},"Lucas Vance","Person",{"url":68,"name":91,"@type":92},"DocShare","Organization","application/pdf","2026-10-07","2026-09-19",true,{"@type":98,"interactionType":99,"userInteractionCount":8},"InteractionCounter",{"@type":100},"ViewAction",{"@type":102,"mainEntity":103},"FAQPage",[104,110,114],{"name":105,"@type":106,"acceptedAnswer":107},"What information does the form request about the applicant’s background?","Question",{"text":108,"@type":109},"It collects basic personal data such as name, relationship details, date of birth, sex, marital status, height, weight, and Emirates visa information, along with email and mobile number.","Answer",{"name":111,"@type":106,"acceptedAnswer":112},"Which COVID-19 related questions are included in the application?",{"text":113,"@type":109},"The form asks whether the applicant ever tested positive for COVID-19, when the last negative test date occurred, and whether there are any post-COVID complications under medical monitoring.",{"name":115,"@type":106,"acceptedAnswer":116},"What happens if an applicant makes a false declaration?",{"text":117,"@type":109},"The form states that false declaration results in no coverage and cancellation of the insurance policy, and that failure to disclose material information invalidates the proposed insurance policy.","https://schema.org",{"og:url":78,"og:type":120,"og:title":59,"og:site_name":91,"og:description":61},"article",{"robots":122,"canonical":78},"index,follow",{"doc_id":124,"site_id":56},306060,1790144231,{"code":4,"msg":5,"data":127},{"doc_id":124,"user_id":128,"nickname":88,"user_avatar":129,"doc_module":9,"category_id":35,"category_name":36,"doc_title":59,"doc_description":61,"doc_content":130,"file_id":131,"file_url":132,"file_type":133,"file_size":134,"view_count":8,"is_deleted":4,"is_public":9,"is_downloadable":9,"audit_status":9,"page_count":76,"language":135,"language_code":57,"site_id":56,"html_lang":57,"table_of_contents":136,"faqs":137,"seo_title":138,"seo_description":61,"update_tm":139,"read_time":9},549768064622,"https://ap-avatar.wpscdn.com/davatar_6f874abed73319feea01a86fa6f0fab8","Medical Application Form  \n\n| NAME | RELATION\u003Cbr>(E/S/C) | D. O. B | SEX\u003Cbr>(M/F) | MARITAL\u003Cbr>STATUS | HEIGHT\u003Cbr>(CM) | WEIGHT\u003Cbr>(KG) | EMIRATES\u003Cbr>(VISA) |\n| --- | --- | --- | --- | --- | --- | --- | --- |\n|  | PRINCIPLE |  |  |  |  |  |  |\n|  | SPOUSE |  |  |  |  |  |  |\n|  | CHILD |  |  |  |  |  |  |\n|  | CHILD |  |  |  |  |  |  |\n|  | CHILD |  |  |  |  |  |  |\n|  |  |  |  |  |  |  |  |\n\n\n| Email ID |  | Mobile number |  |\n| --- | --- | --- | --- |\n\nHave you ever tested positive for COVID-19 ?  \nWhen is the last date you have tested negative for COVID ?   (DD/MM/YYYY)  \nIs there any Post COVID complications under medical monitoring?  \nHave your health insurance request was ever declined or accepted on substandard terms? If yes, then please provide details.  \nIs there any eligible family member kept away from this insurance request? If yes, then please provide details  \nPlease answer all questions mentioned below as either Yes or No:  \n\n| Yes  | No  |\n| --- | --- |\n\n\n| Yes  | No  |\n| --- | --- |\n\n\n| Yes  | No  |\n| --- | --- |\n| Yes  | No  |\n\n\n| No. | Details | Declaration |\n| --- | --- | --- |\n| 1. | Are you under any medical observation/undergoing any medical/ surgical/ treatment or have been advised for the same? | Yes  No  |\n| 2. | Do you have any chronic illness?\u003Cbr>A chronic condition is defined as a disease, illness, or injury that has one or more of the following characteristics: It needs ongoing or long-term monitoring through consultations, examinations, check-ups, and /or tests.\u003Cbr>It needs ongoing or long-term control or relief of symptoms.\u003Cbr>It may require rehabilitation or the patient to be trained to cope with it.\u003Cbr>It continues indefinitely. Symptoms / medical condition may recur or likely to recur. | Yes  No  |\n| 3. | Are you taking any medication (pharmaceutical/alternative medicine) or have been advised? | Yes  No  |\n| 4. | Do you have any physical problems/ disability for which you are undergoing physiotherapy or have been advised for? | Yes  No  |\n| 5. | Have you been admitted in the hospital in the last 10 years? | Yes  No  |\n| 6. | Are you currently pregnant or show signs and symptoms of pregnancy or planning to get pregnant? (This question apply only to married females)\u003Cbr>If the answer to above is YES kindly fill the attached supplementary maternity questionnaire. | Yes  No  |\n| 7. | Do you have any previous surgical history or are you advised to undergo any kind of surgeries in the near future? | Yes  No  |\n| 8. | Have you been ever diagnosed/treated and cured or undergoing treatments for cancer? | Yes  No  |\n| 9. | Is there any other medical condition or disorder or any symptoms that you should be declared, and you are unable to relate to the above-mentioned Questions? | Yes  No  |\n\n❖ Any applicant who is above 60 years of age should mandatorily submit a medical health certificate from a UAE based Registered Medical Practitioner even if there are no medical declarations to be made on the MAF.  \n❖ Have you availed insurance services under MedNet earlier? If yes please provide earlier policy/card numbers with last year of service:    \nPlease fill below details if you have answered any question as “YES” from above.  \n- Please specify name of the patient:    \n- Medical Condition / Diagnosis:  (if we have more than one sickness please use another form)  \n- Diagnosis status:  Cured / No Symptoms  Ongoing Symptoms  Ongoing Hospitalization  Pending Hospitalization  \n Ongoing treatment  Pending treatment  \n- Treatment taken as:  Out-Patient  Hospitalization  Treated both ways  Operated on Date:   \n- Can the illness be described as follows?  Acute  Chronic  Recurrent  \n- Please specify the medication generic names, the brand name as well as the daily/weekly quantity:  \n- In case you are suffering from hypertension, please specify your recent Systolic and Diastolic readings below:  \no Systolic:    \no Diastolic:   \n- In case of diabetes, please specify whether insulin dependent, also specify/attach latest H","cbCaieb8VuYahTw1","https://ap.wps.com/l/cbCaieb8VuYahTw1","pdf",173675,"English","# Medical Applicant Details\n## Personal Information and Contact\n## COVID-19 and Insurance History\n# Medical Declarations (Yes/No)\n## Observations, Chronic Illness, Medications\n## Disability/Physiotherapy, Hospitalization, Pregnancy\n## Surgical History, Cancer, Other Conditions\n# Medical Reports and Declarations\n## Age Above 60 Requirement\n## Details for “YES” Answers\n## Authorization, Consent, and Signature\n# Supplementary Pregnancy Questionnaire\n## Married Female Pregnancy Details","[{\"question\":\"What information does the form request about the applicant’s background?\",\"answer\":\"It collects basic personal data such as name, relationship details, date of birth, sex, marital status, height, weight, and Emirates visa information, along with email and mobile number.\"},{\"question\":\"Which COVID-19 related questions are included in the application?\",\"answer\":\"The form asks whether the applicant ever tested positive for COVID-19, when the last negative test date occurred, and whether there are any post-COVID complications under medical monitoring.\"},{\"question\":\"What happens if an applicant makes a false declaration?\",\"answer\":\"The form states that false declaration results in no coverage and cancellation of the insurance policy, and that failure to disclose material information invalidates the proposed insurance policy.\"}]","Medical-Application-Form-New V3 - Medical Application Form | PDF",1789832588]