I do hereby declare that;
1 |
I am in good health and entirely free from any mental or physical impairments or deformities. |
2 |
Have never suffered from: |
|
a) diseases of the circulatory system (e.g. heart trouble, rheumatic fever, high blood pressure, diseases of the arteries and veins)
|
b) diseases of the respiratory system (e.g. tuberculosis, asthma, persistent cough, pneumonia) |
c) diseases of the genito-urinary system (e.g. infections of the kidneys, urinary or genital organs, renal stones, venereal disease) |
d) diseases of the gastro-intestinal system (e.g. digestive disorders, gastric or duodenal ulcer, hepatitis B or other
disorders of the liver, disorders of the gall bladder) |
e) diseases of the nervous system or mental disorders (e.g. epilepsy, fits or fainting attacks, frequent headaches,
nervous breakdown) |
f) diabetes, cancer, or any diseases of the blood, glands, spleen, ears, eyes or skin |
g) unexplained night-sweats and/or loss of weight, persistent fever, chronic or recurrent diarrhoea, unexplained
infections or swollen glands |
h) any other diseases or ailments not mentioned above |
3 |
Have never been advised to undergo hospital treatment or surgery in the last one year |
4 |
Have never been advised to have a blood test for AIDS or an AIDS-related condition or have you ever been refused as
a blood donor in the last one year |
5 |
Have never consulted a physician for any reason, including routine examinations and blood tests, or have you received
any blood transfusions within the last one year |
6 |
My life insurance/family takaful proposal has not been declined or postponed or been accepted with an extra premium
in the last one year |
7 |
Currently I do not experience any symptoms related to COVID-19 ( i.e. fever, sore throat, dry cough, Headache,
shortness of breath, Fatigue, anosmia, Myalgia/arthralgia and Dysgeusia) |
8 |
I have never been diagnosed as COVID-19 positive |
9 |
During last 14 days I have not came to in contact with COVID-19 positive patient |
10 |
During last 1 month I have not visited any other country and do not have any planning to visit during next 4 months |
I hereby declare that the foregoing statements are full, complete and true. I agree that they shall be the basis of issuance of
my above contract of participant and the Dawood Family Takaful shall not be liable for any claim on account of illness,
injury, or death, the cause of which was known prior to approval of my request for issuance of the contract of takaful
coverage and withheld or concealed in the above statements. I authorize any physician, nurse, hospital official or employee
to disclose to the Dawood Family Takaful any and all information regarding my medical history. |
Coverage Effective Date
Information submitted by you will be reviewed by our underwriter and will notify you through
email/phone regarding acceptance of your proposal or further information/documentation required, if any. The
coverage will start once your proposal is approved and a Certificate is issued.
Waiting Period
A waiting period of 30 days will be applicable from the date of commencement, during this period
only accidental claims will be entertained and sickness related coverage will be effective after lapse of waiting period.