Dear Insured: :

Please Fill out the form correctly for the purpose of pricing and to ensure that you
receive health care services as required according to your unfied policy benefit. .

Addition ¨ New þ
Employee Name: Moustafa Helmi Moustafa Mahmoud : Entity Name: Saudi Efforts Contracting Company :
Gender: Male : Nationality: Egypt : Policy No. / Cr No.: 1010337564 :
ID No: 2401180464 : Mobile No: 0562002798 : Marital Status: Married þ Single ¨ :

Con. Please declare any of below cases for yourself or any of

No / Yes /
No. your dependents by marking ü under the word (Yes): : ü
1. Any hospital admission during the last 12 months. o o 12 .1
2. Have you been diagnosed with any of the following chronic diseases : .2
limited to:
Autism, Benign Tumor, Cancer, Heart Diseases, Chronic Hepatitis C, o o
Gallstones, Kidney failure, Urinary tract stones, thyroid goiter, Cysts,
fibroid uterus, Hernias, autoimmune diseases or Multiple sclerosis.
3. Have you been diagnosed with any of the following congenital disorder
or hereditary diseases limited to:
o o : .3

Cerebral palsy, Sickle cell disorder, Thalassemia, hemophilia, metabolic

diseases, Hydrocephalus, spinal muscle atrophy, genital malformations,
Chromosomal abnormalities, Gaucher’s disease, G6PD Deficiency,
cystic fibrosis, hemochromatosis, Wilson disease, Polycystic Kidney
Disease.

4. Have you been diagnosed with any of the following eye o o : .4

diseases limited to: .
Cataract, Glaucoma, Corneal diseases or Retinal diseases.
5. Have you been diagnosed with any of the following bone diseases o o : .5
limited to:
Vertebral disc prolapse, Scoliosis, Arthritis or Ligament tears.

6. Pregnant Females only: : .6

Current single pregnancy. o o .

Current single pregnancy with previous CS delivery. o o .

Current multiple pregnancy. o o .

Expected delivery date: :

Employee and dependents’ details that need to be added

(Please declare whether there is a medical condition for you or any family member) ( )

Hospital Name Condition Mobile No. Ht. (cm) Wt. (kg) ID# Relationship Gender Employee / Dependent Name

2401180464 Employee Male Moustafa Helmi Moustafa Mahmoud 1

2445300086 Wife Female Shaymaa Said Othman Hessen 2

2445300094 Daughter Female Arwa Moustafa Helmy Mahmoud 3

2459010936 Son Male Ahmed Mahmoud 4

Undertaking

· I hereby undertake that all above information are correct and the acceptance of my ·
enrolment will be on the basis of such information and that (insurance company
name) has the right to contact the hospital(s) I deal with to collect any medical
information needed to assess the risk(s).
· I agree that (insurance company name) has the right to reject the coverage/claims in ·
full in case of no declaration of any cases prior to the contractual date or before
enrolling or adding a new Insured during the contract.
· I hereby confirm reading and understanding all points presented in this form and I
agree that not marking any case is understood as “Nothing requires declaration” and I ·
sign on these basis.
· Failure to fill the weight and height information will result in refusal to cover the cost of ·
obesity surgery.
Entity Stamp Employee Signature Date

09/06/2021
·  Upon renewal of the policy, the insurer shall not request a declaration form for any insured who has been insured for 11 · 
months.
.
·  The insurer is not eligible to request a medical declaration form for newborns when they are added to the existing health . · 
insurance policy. . · 
·  If you need to add more dependents, an additional form should be filled. . · 
·  It is illegal to sign this form by the employer instead of the employee.
Dear Insured: :
Please Fill out the form correctly for the purpose of pricing and to ensure that you
receive health care services as required according to your unfied policy benefit. .

Addition ¨ New þ
Employee Name: Ahmed Ibrahim Ahmed Ali : Entity Name: Saudi Efforts Contracting Company :
Gender: Male : Nationality: Egypt : Policy No. / Cr No.: 1010337564 :
ID No: 2112774837 : Mobile No: 0562002798 : Marital Status: Married þ Single ¨ :

Con. Please declare any of below cases for yourself or any of

No / Yes /
No. your dependents by marking ü under the word (Yes): : ü
1. Any hospital admission during the last 12 months. o o 12 .1
2. Have you been diagnosed with any of the following chronic diseases : .2
limited to:
Autism, Benign Tumor, Cancer, Heart Diseases, Chronic Hepatitis C, o o
Gallstones, Kidney failure, Urinary tract stones, thyroid goiter, Cysts,
fibroid uterus, Hernias, autoimmune diseases or Multiple sclerosis.
3. Have you been diagnosed with any of the following congenital disorder
or hereditary diseases limited to:
o o : .3

Cerebral palsy, Sickle cell disorder, Thalassemia, hemophilia, metabolic

diseases, Hydrocephalus, spinal muscle atrophy, genital malformations,
Chromosomal abnormalities, Gaucher’s disease, G6PD Deficiency,
cystic fibrosis, hemochromatosis, Wilson disease, Polycystic Kidney
Disease.

4. Have you been diagnosed with any of the following eye o o : .4

diseases limited to: .
Cataract, Glaucoma, Corneal diseases or Retinal diseases.
5. Have you been diagnosed with any of the following bone diseases o o : .5
limited to:
Vertebral disc prolapse, Scoliosis, Arthritis or Ligament tears.

6. Pregnant Females only: : .6

Current single pregnancy. o o .

Current single pregnancy with previous CS delivery. o o .

Current multiple pregnancy. o o .

Expected delivery date: :

Employee and dependents’ details that need to be added

(Please declare whether there is a medical condition for you or any family member) ( )

Hospital Name Condition Mobile No. Ht. (cm) Wt. (kg) ID# Relationship Gender Employee / Dependent Name

2112774837 Employee Male Ahmed Ibrahim Ahmed Ali 5

Undertaking

· I hereby undertake that all above information are correct and the acceptance of my ·
enrolment will be on the basis of such information and that (insurance company
name) has the right to contact the hospital(s) I deal with to collect any medical
information needed to assess the risk(s).
· I agree that (insurance company name) has the right to reject the coverage/claims in ·
full in case of no declaration of any cases prior to the contractual date or before
enrolling or adding a new Insured during the contract.
· I hereby confirm reading and understanding all points presented in this form and I
agree that not marking any case is understood as “Nothing requires declaration” and I ·
sign on these basis.
· Failure to fill the weight and height information will result in refusal to cover the cost of ·
obesity surgery.
Entity Stamp Employee Signature Date

09/06/2021
·  Upon renewal of the policy, the insurer shall not request a declaration form for any insured who has been insured for 11 · 
.
months.
·  The insurer is not eligible to request a medical declaration form for newborns when they are added to the existing health . · 
insurance policy. . · 
·  If you need to add more dependents, an additional form should be filled. . · 
·  It is illegal to sign this form by the employer instead of the employee.
Dear Insured: :
Please Fill out the form correctly for the purpose of pricing and to ensure that you
receive health care services as required according to your unfied policy benefit. .

Addition ¨ New þ
Employee Name: Abul Hossain Khelu Miah : Entity Name: Saudi Efforts Contracting Company :
Gender: Male : Nationality: Bangladesh : Policy No. / Cr No.: 1010337564 :
ID No: 2202441081 : Mobile No: 0562002798 : Marital Status: Married þ Single ¨ :

Con. Please declare any of below cases for yourself or any of

No / Yes /
No. your dependents by marking ü under the word (Yes): : ü
1. Any hospital admission during the last 12 months. o o 12 .1
2. Have you been diagnosed with any of the following chronic diseases : .2
limited to:
Autism, Benign Tumor, Cancer, Heart Diseases, Chronic Hepatitis C, o o
Gallstones, Kidney failure, Urinary tract stones, thyroid goiter, Cysts,
fibroid uterus, Hernias, autoimmune diseases or Multiple sclerosis.
3. Have you been diagnosed with any of the following congenital disorder
or hereditary diseases limited to:
o o : .3

Cerebral palsy, Sickle cell disorder, Thalassemia, hemophilia, metabolic

diseases, Hydrocephalus, spinal muscle atrophy, genital malformations,
Chromosomal abnormalities, Gaucher’s disease, G6PD Deficiency,
cystic fibrosis, hemochromatosis, Wilson disease, Polycystic Kidney
Disease.

4. Have you been diagnosed with any of the following eye o o : .4

diseases limited to: .
Cataract, Glaucoma, Corneal diseases or Retinal diseases.
5. Have you been diagnosed with any of the following bone diseases o o : .5
limited to:
Vertebral disc prolapse, Scoliosis, Arthritis or Ligament tears.

6. Pregnant Females only: : .6

Current single pregnancy. o o .

Current single pregnancy with previous CS delivery. o o .

Current multiple pregnancy. o o .

Expected delivery date: :

Employee and dependents’ details that need to be added

(Please declare whether there is a medical condition for you or any family member) ( )

Hospital Name Condition Mobile No. Ht. (cm) Wt. (kg) ID# Relationship Gender Employee / Dependent Name

2202441081 Employee Male Abul Hossain Khelu Miah 6

Undertaking

· I hereby undertake that all above information are correct and the acceptance of my ·
enrolment will be on the basis of such information and that (insurance company
name) has the right to contact the hospital(s) I deal with to collect any medical
information needed to assess the risk(s).
· I agree that (insurance company name) has the right to reject the coverage/claims in ·
full in case of no declaration of any cases prior to the contractual date or before
enrolling or adding a new Insured during the contract.
· I hereby confirm reading and understanding all points presented in this form and I
agree that not marking any case is understood as “Nothing requires declaration” and I ·
sign on these basis.
· Failure to fill the weight and height information will result in refusal to cover the cost of ·
obesity surgery.
Entity Stamp Employee Signature Date

09/06/2021
·  Upon renewal of the policy, the insurer shall not request a declaration form for any insured who has been insured for 11 · 
.
months.
·  The insurer is not eligible to request a medical declaration form for newborns when they are added to the existing health . · 
insurance policy. . · 
·  If you need to add more dependents, an additional form should be filled. . · 
·  It is illegal to sign this form by the employer instead of the employee.
Dear Insured: :
Please Fill out the form correctly for the purpose of pricing and to ensure that you
receive health care services as required according to your unfied policy benefit. .

Addition ¨ New þ
Employee Name: Amdadul Hoqae Md Tajul Islam : Entity Name: Saudi Efforts Contracting Company :
Gender: Male : Nationality: Bangladesh : Policy No. / Cr No.: 1010337564 :
ID No: 2300882566 : Mobile No: 0562002798 : Marital Status: Married ¨ Single þ :

Con. Please declare any of below cases for yourself or any of

No / Yes /
No. your dependents by marking ü under the word (Yes): : ü
1. Any hospital admission during the last 12 months. o o 12 .1
2. Have you been diagnosed with any of the following chronic diseases : .2
limited to:
Autism, Benign Tumor, Cancer, Heart Diseases, Chronic Hepatitis C, o o
Gallstones, Kidney failure, Urinary tract stones, thyroid goiter, Cysts,
fibroid uterus, Hernias, autoimmune diseases or Multiple sclerosis.
3. Have you been diagnosed with any of the following congenital disorder
or hereditary diseases limited to:
o o : .3

Cerebral palsy, Sickle cell disorder, Thalassemia, hemophilia, metabolic

diseases, Hydrocephalus, spinal muscle atrophy, genital malformations,
Chromosomal abnormalities, Gaucher’s disease, G6PD Deficiency,
cystic fibrosis, hemochromatosis, Wilson disease, Polycystic Kidney
Disease.

4. Have you been diagnosed with any of the following eye o o : .4

diseases limited to: .
Cataract, Glaucoma, Corneal diseases or Retinal diseases.
5. Have you been diagnosed with any of the following bone diseases o o : .5
limited to:
Vertebral disc prolapse, Scoliosis, Arthritis or Ligament tears.

6. Pregnant Females only: : .6

Current single pregnancy. o o .

Current single pregnancy with previous CS delivery. o o .

Current multiple pregnancy. o o .

Expected delivery date: :

Employee and dependents’ details that need to be added

(Please declare whether there is a medical condition for you or any family member) ( )

Hospital Name Condition Mobile No. Ht. (cm) Wt. (kg) ID# Relationship Gender Employee / Dependent Name

2300882566 Employee Male Amdadul Hoqae Md Tajul Islam 7

Undertaking

· I hereby undertake that all above information are correct and the acceptance of my ·
enrolment will be on the basis of such information and that (insurance company
name) has the right to contact the hospital(s) I deal with to collect any medical
information needed to assess the risk(s).
· I agree that (insurance company name) has the right to reject the coverage/claims in ·
full in case of no declaration of any cases prior to the contractual date or before
enrolling or adding a new Insured during the contract.
· I hereby confirm reading and understanding all points presented in this form and I
agree that not marking any case is understood as “Nothing requires declaration” and I ·
sign on these basis.
· Failure to fill the weight and height information will result in refusal to cover the cost of ·
obesity surgery.
Entity Stamp Employee Signature Date

09/06/2021
·  Upon renewal of the policy, the insurer shall not request a declaration form for any insured who has been insured for 11 · 
.
months.
·  The insurer is not eligible to request a medical declaration form for newborns when they are added to the existing health . · 
insurance policy. . · 
·  If you need to add more dependents, an additional form should be filled. . · 
·  It is illegal to sign this form by the employer instead of the employee.
Dear Insured: :
Please Fill out the form correctly for the purpose of pricing and to ensure that you
receive health care services as required according to your unfied policy benefit. .

Addition ¨ New þ
Employee Name: Azizulhoque Moinulhassin : Entity Name: Saudi Efforts Contracting Company :
Gender: Male : Nationality: Bangladesh : Policy No. / Cr No.: 1010337564 :
ID No: 2206091213 : Mobile No: 0562002798 : Marital Status: Married þ Single ¨ :

Con. Please declare any of below cases for yourself or any of

No / Yes /
No. your dependents by marking ü under the word (Yes): : ü
1. Any hospital admission during the last 12 months. o o 12 .1
2. Have you been diagnosed with any of the following chronic diseases : .2
limited to:
Autism, Benign Tumor, Cancer, Heart Diseases, Chronic Hepatitis C, o o
Gallstones, Kidney failure, Urinary tract stones, thyroid goiter, Cysts,
fibroid uterus, Hernias, autoimmune diseases or Multiple sclerosis.
3. Have you been diagnosed with any of the following congenital disorder
or hereditary diseases limited to:
o o : .3

Cerebral palsy, Sickle cell disorder, Thalassemia, hemophilia, metabolic

diseases, Hydrocephalus, spinal muscle atrophy, genital malformations,
Chromosomal abnormalities, Gaucher’s disease, G6PD Deficiency,
cystic fibrosis, hemochromatosis, Wilson disease, Polycystic Kidney
Disease.

4. Have you been diagnosed with any of the following eye o o : .4

diseases limited to: .
Cataract, Glaucoma, Corneal diseases or Retinal diseases.
5. Have you been diagnosed with any of the following bone diseases o o : .5
limited to:
Vertebral disc prolapse, Scoliosis, Arthritis or Ligament tears.

6. Pregnant Females only: : .6

Current single pregnancy. o o .

Current single pregnancy with previous CS delivery. o o .

Current multiple pregnancy. o o .

Expected delivery date: :

Employee and dependents’ details that need to be added

(Please declare whether there is a medical condition for you or any family member) ( )

Hospital Name Condition Mobile No. Ht. (cm) Wt. (kg) ID# Relationship Gender Employee / Dependent Name

2206091213 Employee Male Azizulhoque Moinulhassin 8

Undertaking

· I hereby undertake that all above information are correct and the acceptance of my ·
enrolment will be on the basis of such information and that (insurance company
name) has the right to contact the hospital(s) I deal with to collect any medical
information needed to assess the risk(s).
· I agree that (insurance company name) has the right to reject the coverage/claims in ·
full in case of no declaration of any cases prior to the contractual date or before
enrolling or adding a new Insured during the contract.
· I hereby confirm reading and understanding all points presented in this form and I
agree that not marking any case is understood as “Nothing requires declaration” and I ·
sign on these basis.
· Failure to fill the weight and height information will result in refusal to cover the cost of ·
obesity surgery.
Entity Stamp Employee Signature Date

09/06/2021
·  Upon renewal of the policy, the insurer shall not request a declaration form for any insured who has been insured for 11 · 
.
months.
·  The insurer is not eligible to request a medical declaration form for newborns when they are added to the existing health . · 
insurance policy. . · 
·  If you need to add more dependents, an additional form should be filled. . · 
·  It is illegal to sign this form by the employer instead of the employee.
Dear Insured: :
Please Fill out the form correctly for the purpose of pricing and to ensure that you
receive health care services as required according to your unfied policy benefit. .

Addition ¨ New þ
Employee Name: Md Nazmul Hoque Bhuiyan Rubel : Entity Name: Saudi Efforts Contracting Company :
Gender: Male : Nationality: Bangladesh : Policy No. / Cr No.: 1010337564 :
ID No: 2431505912 : Mobile No: 0562002798 : Marital Status: Married ¨ Single þ :

Con. Please declare any of below cases for yourself or any of

No / Yes /
No. your dependents by marking ü under the word (Yes): : ü
1. Any hospital admission during the last 12 months. o o 12 .1
2. Have you been diagnosed with any of the following chronic diseases : .2
limited to:
Autism, Benign Tumor, Cancer, Heart Diseases, Chronic Hepatitis C, o o
Gallstones, Kidney failure, Urinary tract stones, thyroid goiter, Cysts,
fibroid uterus, Hernias, autoimmune diseases or Multiple sclerosis.
3. Have you been diagnosed with any of the following congenital disorder
or hereditary diseases limited to:
o o : .3

Cerebral palsy, Sickle cell disorder, Thalassemia, hemophilia, metabolic

diseases, Hydrocephalus, spinal muscle atrophy, genital malformations,
Chromosomal abnormalities, Gaucher’s disease, G6PD Deficiency,
cystic fibrosis, hemochromatosis, Wilson disease, Polycystic Kidney
Disease.

4. Have you been diagnosed with any of the following eye o o : .4

diseases limited to: .
Cataract, Glaucoma, Corneal diseases or Retinal diseases.
5. Have you been diagnosed with any of the following bone diseases o o : .5
limited to:
Vertebral disc prolapse, Scoliosis, Arthritis or Ligament tears.

6. Pregnant Females only: : .6

Current single pregnancy. o o .

Current single pregnancy with previous CS delivery. o o .

Current multiple pregnancy. o o .

Expected delivery date: :

Employee and dependents’ details that need to be added

(Please declare whether there is a medical condition for you or any family member) ( )

Hospital Name Condition Mobile No. Ht. (cm) Wt. (kg) ID# Relationship Gender Employee / Dependent Name

2431505912 Employee Male Md Nazmul Hoque Bhuiyan Rubel 9

Undertaking

· I hereby undertake that all above information are correct and the acceptance of my ·
enrolment will be on the basis of such information and that (insurance company
name) has the right to contact the hospital(s) I deal with to collect any medical
information needed to assess the risk(s).
· I agree that (insurance company name) has the right to reject the coverage/claims in ·
full in case of no declaration of any cases prior to the contractual date or before
enrolling or adding a new Insured during the contract.
· I hereby confirm reading and understanding all points presented in this form and I
agree that not marking any case is understood as “Nothing requires declaration” and I ·
sign on these basis.
· Failure to fill the weight and height information will result in refusal to cover the cost of ·
obesity surgery.
Entity Stamp Employee Signature Date

09/06/2021
·  Upon renewal of the policy, the insurer shall not request a declaration form for any insured who has been insured for 11 · 
.
months.
·  The insurer is not eligible to request a medical declaration form for newborns when they are added to the existing health . · 
insurance policy. . · 
·  If you need to add more dependents, an additional form should be filled. . · 
·  It is illegal to sign this form by the employer instead of the employee.
Dear Insured: :
Please Fill out the form correctly for the purpose of pricing and to ensure that you
receive health care services as required according to your unfied policy benefit. .

Addition ¨ New þ
Employee Name: Delower G Ain : Entity Name: Saudi Efforts Contracting Company :
Gender: Male : Nationality: Bangladesh : Policy No. / Cr No.: 1010337564 :
ID No: 2158119939 : Mobile No: 0562002798 : Marital Status: Married þ Single ¨ :

Con. Please declare any of below cases for yourself or any of

No / Yes /
No. your dependents by marking ü under the word (Yes): : ü
1. Any hospital admission during the last 12 months. o o 12 .1
2. Have you been diagnosed with any of the following chronic diseases : .2
limited to:
Autism, Benign Tumor, Cancer, Heart Diseases, Chronic Hepatitis C, o o
Gallstones, Kidney failure, Urinary tract stones, thyroid goiter, Cysts,
fibroid uterus, Hernias, autoimmune diseases or Multiple sclerosis.
3. Have you been diagnosed with any of the following congenital disorder
or hereditary diseases limited to:
o o : .3

Cerebral palsy, Sickle cell disorder, Thalassemia, hemophilia, metabolic

diseases, Hydrocephalus, spinal muscle atrophy, genital malformations,
Chromosomal abnormalities, Gaucher’s disease, G6PD Deficiency,
cystic fibrosis, hemochromatosis, Wilson disease, Polycystic Kidney
Disease.

4. Have you been diagnosed with any of the following eye o o : .4

diseases limited to: .
Cataract, Glaucoma, Corneal diseases or Retinal diseases.
5. Have you been diagnosed with any of the following bone diseases o o : .5
limited to:
Vertebral disc prolapse, Scoliosis, Arthritis or Ligament tears.

6. Pregnant Females only: : .6

Current single pregnancy. o o .

Current single pregnancy with previous CS delivery. o o .

Current multiple pregnancy. o o .

Expected delivery date: :

Employee and dependents’ details that need to be added

(Please declare whether there is a medical condition for you or any family member) ( )

Hospital Name Condition Mobile No. Ht. (cm) Wt. (kg) ID# Relationship Gender Employee / Dependent Name

2158119939 Employee Male Delower G Ain 10

Undertaking

· I hereby undertake that all above information are correct and the acceptance of my ·
enrolment will be on the basis of such information and that (insurance company
name) has the right to contact the hospital(s) I deal with to collect any medical
information needed to assess the risk(s).
· I agree that (insurance company name) has the right to reject the coverage/claims in ·
full in case of no declaration of any cases prior to the contractual date or before
enrolling or adding a new Insured during the contract.
· I hereby confirm reading and understanding all points presented in this form and I
agree that not marking any case is understood as “Nothing requires declaration” and I ·
sign on these basis.
· Failure to fill the weight and height information will result in refusal to cover the cost of ·
obesity surgery.
Entity Stamp Employee Signature Date

09/06/2021
·  Upon renewal of the policy, the insurer shall not request a declaration form for any insured who has been insured for 11 · 
.
months.
·  The insurer is not eligible to request a medical declaration form for newborns when they are added to the existing health . · 
insurance policy. . · 
·  If you need to add more dependents, an additional form should be filled. . · 
·  It is illegal to sign this form by the employer instead of the employee.
Dear Insured: :
Please Fill out the form correctly for the purpose of pricing and to ensure that you
receive health care services as required according to your unfied policy benefit. .

Addition ¨ New þ
Employee Name: Hajee Basha Shaik : Entity Name: Saudi Efforts Contracting Company :
Gender: Male : Nationality: India : Policy No. / Cr No.: 1010337564 :
ID No: 2424776363 : Mobile No: 0562002798 : Marital Status: Married ¨ Single þ :

Con. Please declare any of below cases for yourself or any of

No / Yes /
No. your dependents by marking ü under the word (Yes): : ü
1. Any hospital admission during the last 12 months. o o 12 .1
2. Have you been diagnosed with any of the following chronic diseases : .2
limited to:
Autism, Benign Tumor, Cancer, Heart Diseases, Chronic Hepatitis C, o o
Gallstones, Kidney failure, Urinary tract stones, thyroid goiter, Cysts,
fibroid uterus, Hernias, autoimmune diseases or Multiple sclerosis.
3. Have you been diagnosed with any of the following congenital disorder
or hereditary diseases limited to:
o o : .3

Cerebral palsy, Sickle cell disorder, Thalassemia, hemophilia, metabolic

diseases, Hydrocephalus, spinal muscle atrophy, genital malformations,
Chromosomal abnormalities, Gaucher’s disease, G6PD Deficiency,
cystic fibrosis, hemochromatosis, Wilson disease, Polycystic Kidney
Disease.

4. Have you been diagnosed with any of the following eye o o : .4

diseases limited to: .
Cataract, Glaucoma, Corneal diseases or Retinal diseases.
5. Have you been diagnosed with any of the following bone diseases o o : .5
limited to:
Vertebral disc prolapse, Scoliosis, Arthritis or Ligament tears.

6. Pregnant Females only: : .6

Current single pregnancy. o o .

Current single pregnancy with previous CS delivery. o o .

Current multiple pregnancy. o o .

Expected delivery date: :

Employee and dependents’ details that need to be added

(Please declare whether there is a medical condition for you or any family member) ( )

Hospital Name Condition Mobile No. Ht. (cm) Wt. (kg) ID# Relationship Gender Employee / Dependent Name

2424776363 Employee Male Hajee Basha Shaik 11

Undertaking

· I hereby undertake that all above information are correct and the acceptance of my ·
enrolment will be on the basis of such information and that (insurance company
name) has the right to contact the hospital(s) I deal with to collect any medical
information needed to assess the risk(s).
· I agree that (insurance company name) has the right to reject the coverage/claims in ·
full in case of no declaration of any cases prior to the contractual date or before
enrolling or adding a new Insured during the contract.
· I hereby confirm reading and understanding all points presented in this form and I
agree that not marking any case is understood as “Nothing requires declaration” and I ·
sign on these basis.
· Failure to fill the weight and height information will result in refusal to cover the cost of ·
obesity surgery.
Entity Stamp Employee Signature Date

09/06/2021
·  Upon renewal of the policy, the insurer shall not request a declaration form for any insured who has been insured for 11 · 
.
months.
·  The insurer is not eligible to request a medical declaration form for newborns when they are added to the existing health . · 
insurance policy. . · 
·  If you need to add more dependents, an additional form should be filled. . · 
·  It is illegal to sign this form by the employer instead of the employee.
Dear Insured: :
Please Fill out the form correctly for the purpose of pricing and to ensure that you
receive health care services as required according to your unfied policy benefit. .

Addition ¨ New þ
Employee Name: Helaluddin Hero Miah : Entity Name: Saudi Efforts Contracting Company :
Gender: Male : Nationality: Bangladesh : Policy No. / Cr No.: 1010337564 :
ID No: 2205420199 : Mobile No: 0562002798 : Marital Status: Married þ Single ¨ :

Con. Please declare any of below cases for yourself or any of

No / Yes /
No. your dependents by marking ü under the word (Yes): : ü
1. Any hospital admission during the last 12 months. o o 12 .1
2. Have you been diagnosed with any of the following chronic diseases : .2
limited to:
Autism, Benign Tumor, Cancer, Heart Diseases, Chronic Hepatitis C, o o
Gallstones, Kidney failure, Urinary tract stones, thyroid goiter, Cysts,
fibroid uterus, Hernias, autoimmune diseases or Multiple sclerosis.
3. Have you been diagnosed with any of the following congenital disorder
or hereditary diseases limited to:
o o : .3

Cerebral palsy, Sickle cell disorder, Thalassemia, hemophilia, metabolic

diseases, Hydrocephalus, spinal muscle atrophy, genital malformations,
Chromosomal abnormalities, Gaucher’s disease, G6PD Deficiency,
cystic fibrosis, hemochromatosis, Wilson disease, Polycystic Kidney
Disease.

4. Have you been diagnosed with any of the following eye o o : .4

diseases limited to: .
Cataract, Glaucoma, Corneal diseases or Retinal diseases.
5. Have you been diagnosed with any of the following bone diseases o o : .5
limited to:
Vertebral disc prolapse, Scoliosis, Arthritis or Ligament tears.

6. Pregnant Females only: : .6

Current single pregnancy. o o .

Current single pregnancy with previous CS delivery. o o .

Current multiple pregnancy. o o .

Expected delivery date: :

Employee and dependents’ details that need to be added

(Please declare whether there is a medical condition for you or any family member) ( )

Hospital Name Condition Mobile No. Ht. (cm) Wt. (kg) ID# Relationship Gender Employee / Dependent Name

2205420199 Employee Male Helaluddin Hero Miah 12

Undertaking

· I hereby undertake that all above information are correct and the acceptance of my ·
enrolment will be on the basis of such information and that (insurance company
name) has the right to contact the hospital(s) I deal with to collect any medical
information needed to assess the risk(s).
· I agree that (insurance company name) has the right to reject the coverage/claims in ·
full in case of no declaration of any cases prior to the contractual date or before
enrolling or adding a new Insured during the contract.
· I hereby confirm reading and understanding all points presented in this form and I
agree that not marking any case is understood as “Nothing requires declaration” and I ·
sign on these basis.
· Failure to fill the weight and height information will result in refusal to cover the cost of ·
obesity surgery.
Entity Stamp Employee Signature Date

09/06/2021
·  Upon renewal of the policy, the insurer shall not request a declaration form for any insured who has been insured for 11 · 
.
months.
·  The insurer is not eligible to request a medical declaration form for newborns when they are added to the existing health . · 
insurance policy. . · 
·  If you need to add more dependents, an additional form should be filled. . · 
·  It is illegal to sign this form by the employer instead of the employee.
Dear Insured: :
Please Fill out the form correctly for the purpose of pricing and to ensure that you
receive health care services as required according to your unfied policy benefit. .

Addition ¨ New þ
Employee Name: Jahangir Md Altab Hossain : Entity Name: Saudi Efforts Contracting Company :
Gender: Male : Nationality: Bangladesh : Policy No. / Cr No.: 1010337564 :
ID No: 2246534446 : Mobile No: 0562002798 : Marital Status: Married þ Single ¨ :

Con. Please declare any of below cases for yourself or any of

No / Yes /
No. your dependents by marking ü under the word (Yes): : ü
1. Any hospital admission during the last 12 months. o o 12 .1
2. Have you been diagnosed with any of the following chronic diseases : .2
limited to:
Autism, Benign Tumor, Cancer, Heart Diseases, Chronic Hepatitis C, o o
Gallstones, Kidney failure, Urinary tract stones, thyroid goiter, Cysts,
fibroid uterus, Hernias, autoimmune diseases or Multiple sclerosis.
3. Have you been diagnosed with any of the following congenital disorder
or hereditary diseases limited to:
o o : .3

Cerebral palsy, Sickle cell disorder, Thalassemia, hemophilia, metabolic

diseases, Hydrocephalus, spinal muscle atrophy, genital malformations,
Chromosomal abnormalities, Gaucher’s disease, G6PD Deficiency,
cystic fibrosis, hemochromatosis, Wilson disease, Polycystic Kidney
Disease.

4. Have you been diagnosed with any of the following eye o o : .4

diseases limited to: .
Cataract, Glaucoma, Corneal diseases or Retinal diseases.
5. Have you been diagnosed with any of the following bone diseases o o : .5
limited to:
Vertebral disc prolapse, Scoliosis, Arthritis or Ligament tears.

6. Pregnant Females only: : .6

Current single pregnancy. o o .

Current single pregnancy with previous CS delivery. o o .

Current multiple pregnancy. o o .

Expected delivery date: :

Employee and dependents’ details that need to be added

(Please declare whether there is a medical condition for you or any family member) ( )

Hospital Name Condition Mobile No. Ht. (cm) Wt. (kg) ID# Relationship Gender Employee / Dependent Name

2246534446 Employee Male Jahangir Md Altab Hossain 13

Undertaking

· I hereby undertake that all above information are correct and the acceptance of my ·
enrolment will be on the basis of such information and that (insurance company
name) has the right to contact the hospital(s) I deal with to collect any medical
information needed to assess the risk(s).
· I agree that (insurance company name) has the right to reject the coverage/claims in ·
full in case of no declaration of any cases prior to the contractual date or before
enrolling or adding a new Insured during the contract.
· I hereby confirm reading and understanding all points presented in this form and I
agree that not marking any case is understood as “Nothing requires declaration” and I ·
sign on these basis.
· Failure to fill the weight and height information will result in refusal to cover the cost of ·
obesity surgery.
Entity Stamp Employee Signature Date

09/06/2021
·  Upon renewal of the policy, the insurer shall not request a declaration form for any insured who has been insured for 11 · 
.
months.
·  The insurer is not eligible to request a medical declaration form for newborns when they are added to the existing health . · 
insurance policy. . · 
·  If you need to add more dependents, an additional form should be filled. . · 
·  It is illegal to sign this form by the employer instead of the employee.
Dear Insured: :
Please Fill out the form correctly for the purpose of pricing and to ensure that you
receive health care services as required according to your unfied policy benefit. .

Addition ¨ New þ
Employee Name: Jahangirhossain Hirumiah : Entity Name: Saudi Efforts Contracting Company :
Gender: Male : Nationality: Bangladesh : Policy No. / Cr No.: 1010337564 :
ID No: 2153561937 : Mobile No: 0562002798 : Marital Status: Married þ Single ¨ :

Con. Please declare any of below cases for yourself or any of

No / Yes /
No. your dependents by marking ü under the word (Yes): : ü
1. Any hospital admission during the last 12 months. o o 12 .1
2. Have you been diagnosed with any of the following chronic diseases : .2
limited to:
Autism, Benign Tumor, Cancer, Heart Diseases, Chronic Hepatitis C, o o
Gallstones, Kidney failure, Urinary tract stones, thyroid goiter, Cysts,
fibroid uterus, Hernias, autoimmune diseases or Multiple sclerosis.
3. Have you been diagnosed with any of the following congenital disorder
or hereditary diseases limited to:
o o : .3

Cerebral palsy, Sickle cell disorder, Thalassemia, hemophilia, metabolic

diseases, Hydrocephalus, spinal muscle atrophy, genital malformations,
Chromosomal abnormalities, Gaucher’s disease, G6PD Deficiency,
cystic fibrosis, hemochromatosis, Wilson disease, Polycystic Kidney
Disease.

4. Have you been diagnosed with any of the following eye o o : .4

diseases limited to: .
Cataract, Glaucoma, Corneal diseases or Retinal diseases.
5. Have you been diagnosed with any of the following bone diseases o o : .5
limited to:
Vertebral disc prolapse, Scoliosis, Arthritis or Ligament tears.

6. Pregnant Females only: : .6

Current single pregnancy. o o .

Current single pregnancy with previous CS delivery. o o .

Current multiple pregnancy. o o .

Expected delivery date: :

Employee and dependents’ details that need to be added

(Please declare whether there is a medical condition for you or any family member) ( )

Hospital Name Condition Mobile No. Ht. (cm) Wt. (kg) ID# Relationship Gender Employee / Dependent Name

2153561937 Employee Male Jahangirhossain Hirumiah 14

Undertaking

· I hereby undertake that all above information are correct and the acceptance of my ·
enrolment will be on the basis of such information and that (insurance company
name) has the right to contact the hospital(s) I deal with to collect any medical
information needed to assess the risk(s).
· I agree that (insurance company name) has the right to reject the coverage/claims in ·
full in case of no declaration of any cases prior to the contractual date or before
enrolling or adding a new Insured during the contract.
· I hereby confirm reading and understanding all points presented in this form and I
agree that not marking any case is understood as “Nothing requires declaration” and I ·
sign on these basis.
· Failure to fill the weight and height information will result in refusal to cover the cost of ·
obesity surgery.
Entity Stamp Employee Signature Date

09/06/2021
·  Upon renewal of the policy, the insurer shall not request a declaration form for any insured who has been insured for 11 · 
.
months.
·  The insurer is not eligible to request a medical declaration form for newborns when they are added to the existing health . · 
insurance policy. . · 
·  If you need to add more dependents, an additional form should be filled. . · 
·  It is illegal to sign this form by the employer instead of the employee.
Dear Insured: :
Please Fill out the form correctly for the purpose of pricing and to ensure that you
receive health care services as required according to your unfied policy benefit. .

Addition ¨ New þ
Employee Name: Mohammad Idris : Entity Name: Saudi Efforts Contracting Company :
Gender: Male : Nationality: Bangladesh : Policy No. / Cr No.: 1010337564 :
ID No: 2429086982 : Mobile No: 0562002798 : Marital Status: Married ¨ Single þ :

Con. Please declare any of below cases for yourself or any of

No / Yes /
No. your dependents by marking ü under the word (Yes): : ü
1. Any hospital admission during the last 12 months. o o 12 .1
2. Have you been diagnosed with any of the following chronic diseases : .2
limited to:
Autism, Benign Tumor, Cancer, Heart Diseases, Chronic Hepatitis C, o o
Gallstones, Kidney failure, Urinary tract stones, thyroid goiter, Cysts,
fibroid uterus, Hernias, autoimmune diseases or Multiple sclerosis.
3. Have you been diagnosed with any of the following congenital disorder
or hereditary diseases limited to:
o o : .3

Cerebral palsy, Sickle cell disorder, Thalassemia, hemophilia, metabolic

diseases, Hydrocephalus, spinal muscle atrophy, genital malformations,
Chromosomal abnormalities, Gaucher’s disease, G6PD Deficiency,
cystic fibrosis, hemochromatosis, Wilson disease, Polycystic Kidney
Disease.

4. Have you been diagnosed with any of the following eye o o : .4

diseases limited to: .
Cataract, Glaucoma, Corneal diseases or Retinal diseases.
5. Have you been diagnosed with any of the following bone diseases o o : .5
limited to:
Vertebral disc prolapse, Scoliosis, Arthritis or Ligament tears.

6. Pregnant Females only: : .6

Current single pregnancy. o o .

Current single pregnancy with previous CS delivery. o o .

Current multiple pregnancy. o o .

Expected delivery date: :

Employee and dependents’ details that need to be added

(Please declare whether there is a medical condition for you or any family member) ( )

Hospital Name Condition Mobile No. Ht. (cm) Wt. (kg) ID# Relationship Gender Employee / Dependent Name

2429086982 Employee Male Mohammad Idris 15

Undertaking

· I hereby undertake that all above information are correct and the acceptance of my ·
enrolment will be on the basis of such information and that (insurance company
name) has the right to contact the hospital(s) I deal with to collect any medical
information needed to assess the risk(s).
· I agree that (insurance company name) has the right to reject the coverage/claims in ·
full in case of no declaration of any cases prior to the contractual date or before
enrolling or adding a new Insured during the contract.
· I hereby confirm reading and understanding all points presented in this form and I
agree that not marking any case is understood as “Nothing requires declaration” and I ·
sign on these basis.
· Failure to fill the weight and height information will result in refusal to cover the cost of ·
obesity surgery.
Entity Stamp Employee Signature Date

09/06/2021
·  Upon renewal of the policy, the insurer shall not request a declaration form for any insured who has been insured for 11 · 
.
months.
·  The insurer is not eligible to request a medical declaration form for newborns when they are added to the existing health . · 
insurance policy. . · 
·  If you need to add more dependents, an additional form should be filled. . · 
·  It is illegal to sign this form by the employer instead of the employee.
Dear Insured: :
Please Fill out the form correctly for the purpose of pricing and to ensure that you
receive health care services as required according to your unfied policy benefit. .

Addition ¨ New þ
Employee Name: Md Zubayer Hossian Md : Entity Name: Saudi Efforts Contracting Company :
Gender: Male : Nationality: Bangladesh : Policy No. / Cr No.: 1010337564 :
ID No: 2257830428 : Mobile No: 0562002798 : Marital Status: Married þ Single ¨ :

Con. Please declare any of below cases for yourself or any of

No / Yes /
No. your dependents by marking ü under the word (Yes): : ü
1. Any hospital admission during the last 12 months. o o 12 .1
2. Have you been diagnosed with any of the following chronic diseases : .2
limited to:
Autism, Benign Tumor, Cancer, Heart Diseases, Chronic Hepatitis C, o o
Gallstones, Kidney failure, Urinary tract stones, thyroid goiter, Cysts,
fibroid uterus, Hernias, autoimmune diseases or Multiple sclerosis.
3. Have you been diagnosed with any of the following congenital disorder
or hereditary diseases limited to:
o o : .3

Cerebral palsy, Sickle cell disorder, Thalassemia, hemophilia, metabolic

diseases, Hydrocephalus, spinal muscle atrophy, genital malformations,
Chromosomal abnormalities, Gaucher’s disease, G6PD Deficiency,
cystic fibrosis, hemochromatosis, Wilson disease, Polycystic Kidney
Disease.

4. Have you been diagnosed with any of the following eye o o : .4

diseases limited to: .
Cataract, Glaucoma, Corneal diseases or Retinal diseases.
5. Have you been diagnosed with any of the following bone diseases o o : .5
limited to:
Vertebral disc prolapse, Scoliosis, Arthritis or Ligament tears.

6. Pregnant Females only: : .6

Current single pregnancy. o o .

Current single pregnancy with previous CS delivery. o o .

Current multiple pregnancy. o o .

Expected delivery date: :

Employee and dependents’ details that need to be added

(Please declare whether there is a medical condition for you or any family member) ( )

Hospital Name Condition Mobile No. Ht. (cm) Wt. (kg) ID# Relationship Gender Employee / Dependent Name

2257830428 Employee Male Md Zubayer Hossian Md 16

Undertaking

· I hereby undertake that all above information are correct and the acceptance of my ·
enrolment will be on the basis of such information and that (insurance company
name) has the right to contact the hospital(s) I deal with to collect any medical
information needed to assess the risk(s).
· I agree that (insurance company name) has the right to reject the coverage/claims in ·
full in case of no declaration of any cases prior to the contractual date or before
enrolling or adding a new Insured during the contract.
· I hereby confirm reading and understanding all points presented in this form and I
agree that not marking any case is understood as “Nothing requires declaration” and I ·
sign on these basis.
· Failure to fill the weight and height information will result in refusal to cover the cost of ·
obesity surgery.
Entity Stamp Employee Signature Date

09/06/2021
·  Upon renewal of the policy, the insurer shall not request a declaration form for any insured who has been insured for 11 · 
.
months.
·  The insurer is not eligible to request a medical declaration form for newborns when they are added to the existing health . · 
insurance policy. . · 
·  If you need to add more dependents, an additional form should be filled. . · 
·  It is illegal to sign this form by the employer instead of the employee.
Dear Insured: :
Please Fill out the form correctly for the purpose of pricing and to ensure that you
receive health care services as required according to your unfied policy benefit. .

Addition ¨ New þ
Employee Name: Mohammed Monser Ali Mohammed : Entity Name: Saudi Efforts Contracting Company :
Gender: Male : Nationality: Bangladesh : Policy No. / Cr No.: 1010337564 :
ID No: 2191703756 : Mobile No: 0562002798 : Marital Status: Married ¨ Single þ :

Con. Please declare any of below cases for yourself or any of

No / Yes /
No. your dependents by marking ü under the word (Yes): : ü
1. Any hospital admission during the last 12 months. o o 12 .1
2. Have you been diagnosed with any of the following chronic diseases : .2
limited to:
Autism, Benign Tumor, Cancer, Heart Diseases, Chronic Hepatitis C, o o
Gallstones, Kidney failure, Urinary tract stones, thyroid goiter, Cysts,
fibroid uterus, Hernias, autoimmune diseases or Multiple sclerosis.
3. Have you been diagnosed with any of the following congenital disorder
or hereditary diseases limited to:
o o : .3

Cerebral palsy, Sickle cell disorder, Thalassemia, hemophilia, metabolic

diseases, Hydrocephalus, spinal muscle atrophy, genital malformations,
Chromosomal abnormalities, Gaucher’s disease, G6PD Deficiency,
cystic fibrosis, hemochromatosis, Wilson disease, Polycystic Kidney
Disease.

4. Have you been diagnosed with any of the following eye o o : .4

diseases limited to: .
Cataract, Glaucoma, Corneal diseases or Retinal diseases.
5. Have you been diagnosed with any of the following bone diseases o o : .5
limited to:
Vertebral disc prolapse, Scoliosis, Arthritis or Ligament tears.

6. Pregnant Females only: : .6

Current single pregnancy. o o .

Current single pregnancy with previous CS delivery. o o .

Current multiple pregnancy. o o .

Expected delivery date: :

Employee and dependents’ details that need to be added

(Please declare whether there is a medical condition for you or any family member) ( )

Hospital Name Condition Mobile No. Ht. (cm) Wt. (kg) ID# Relationship Gender Employee / Dependent Name

2191703756 Employee Male Mohammed Monser Ali Mohammed 17

Undertaking

· I hereby undertake that all above information are correct and the acceptance of my ·
enrolment will be on the basis of such information and that (insurance company
name) has the right to contact the hospital(s) I deal with to collect any medical
information needed to assess the risk(s).
· I agree that (insurance company name) has the right to reject the coverage/claims in ·
full in case of no declaration of any cases prior to the contractual date or before
enrolling or adding a new Insured during the contract.
· I hereby confirm reading and understanding all points presented in this form and I
agree that not marking any case is understood as “Nothing requires declaration” and I ·
sign on these basis.
· Failure to fill the weight and height information will result in refusal to cover the cost of ·
obesity surgery.
Entity Stamp Employee Signature Date

09/06/2021
·  Upon renewal of the policy, the insurer shall not request a declaration form for any insured who has been insured for 11 · 
.
months.
·  The insurer is not eligible to request a medical declaration form for newborns when they are added to the existing health . · 
insurance policy. . · 
·  If you need to add more dependents, an additional form should be filled. . · 
·  It is illegal to sign this form by the employer instead of the employee.
Dear Insured: :
Please Fill out the form correctly for the purpose of pricing and to ensure that you
receive health care services as required according to your unfied policy benefit. .

Addition ¨ New þ
Employee Name: Momin Bhuiyan Mojnu Bhuiyan : Entity Name: Saudi Efforts Contracting Company :
Gender: Male : Nationality: Bangladesh : Policy No. / Cr No.: 1010337564 :
ID No: 2206091353 : Mobile No: 0562002798 : Marital Status: Married þ Single ¨ :

Con. Please declare any of below cases for yourself or any of

No / Yes /
No. your dependents by marking ü under the word (Yes): : ü
1. Any hospital admission during the last 12 months. o o 12 .1
2. Have you been diagnosed with any of the following chronic diseases : .2
limited to:
Autism, Benign Tumor, Cancer, Heart Diseases, Chronic Hepatitis C, o o
Gallstones, Kidney failure, Urinary tract stones, thyroid goiter, Cysts,
fibroid uterus, Hernias, autoimmune diseases or Multiple sclerosis.
3. Have you been diagnosed with any of the following congenital disorder
or hereditary diseases limited to:
o o : .3

Cerebral palsy, Sickle cell disorder, Thalassemia, hemophilia, metabolic

diseases, Hydrocephalus, spinal muscle atrophy, genital malformations,
Chromosomal abnormalities, Gaucher’s disease, G6PD Deficiency,
cystic fibrosis, hemochromatosis, Wilson disease, Polycystic Kidney
Disease.

4. Have you been diagnosed with any of the following eye o o : .4

diseases limited to: .
Cataract, Glaucoma, Corneal diseases or Retinal diseases.
5. Have you been diagnosed with any of the following bone diseases o o : .5
limited to:
Vertebral disc prolapse, Scoliosis, Arthritis or Ligament tears.

6. Pregnant Females only: : .6

Current single pregnancy. o o .

Current single pregnancy with previous CS delivery. o o .

Current multiple pregnancy. o o .

Expected delivery date: :

Employee and dependents’ details that need to be added

(Please declare whether there is a medical condition for you or any family member) ( )

Hospital Name Condition Mobile No. Ht. (cm) Wt. (kg) ID# Relationship Gender Employee / Dependent Name

2206091353 Employee Male Momin Bhuiyan Mojnu Bhuiyan 18

Undertaking

· I hereby undertake that all above information are correct and the acceptance of my ·
enrolment will be on the basis of such information and that (insurance company
name) has the right to contact the hospital(s) I deal with to collect any medical
information needed to assess the risk(s).
· I agree that (insurance company name) has the right to reject the coverage/claims in ·
full in case of no declaration of any cases prior to the contractual date or before
enrolling or adding a new Insured during the contract.
· I hereby confirm reading and understanding all points presented in this form and I
agree that not marking any case is understood as “Nothing requires declaration” and I ·
sign on these basis.
· Failure to fill the weight and height information will result in refusal to cover the cost of ·
obesity surgery.
Entity Stamp Employee Signature Date

09/06/2021
·  Upon renewal of the policy, the insurer shall not request a declaration form for any insured who has been insured for 11 · 
.
months.
·  The insurer is not eligible to request a medical declaration form for newborns when they are added to the existing health . · 
insurance policy. . · 
·  If you need to add more dependents, an additional form should be filled. . · 
·  It is illegal to sign this form by the employer instead of the employee.
Dear Insured: :
Please Fill out the form correctly for the purpose of pricing and to ensure that you
receive health care services as required according to your unfied policy benefit. .

Addition ¨ New þ
Employee Name: Moniru Zzaman Abdu Rashid : Entity Name: Saudi Efforts Contracting Company :
Gender: Male : Nationality: Bangladesh : Policy No. / Cr No.: 1010337564 :
ID No: 2176680730 : Mobile No: 0562002798 : Marital Status: Married þ Single ¨ :

Con. Please declare any of below cases for yourself or any of

No / Yes /
No. your dependents by marking ü under the word (Yes): : ü
1. Any hospital admission during the last 12 months. o o 12 .1
2. Have you been diagnosed with any of the following chronic diseases : .2
limited to:
Autism, Benign Tumor, Cancer, Heart Diseases, Chronic Hepatitis C, o o
Gallstones, Kidney failure, Urinary tract stones, thyroid goiter, Cysts,
fibroid uterus, Hernias, autoimmune diseases or Multiple sclerosis.
3. Have you been diagnosed with any of the following congenital disorder
or hereditary diseases limited to:
o o : .3

Cerebral palsy, Sickle cell disorder, Thalassemia, hemophilia, metabolic

diseases, Hydrocephalus, spinal muscle atrophy, genital malformations,
Chromosomal abnormalities, Gaucher’s disease, G6PD Deficiency,
cystic fibrosis, hemochromatosis, Wilson disease, Polycystic Kidney
Disease.

4. Have you been diagnosed with any of the following eye o o : .4

diseases limited to: .
Cataract, Glaucoma, Corneal diseases or Retinal diseases.
5. Have you been diagnosed with any of the following bone diseases o o : .5
limited to:
Vertebral disc prolapse, Scoliosis, Arthritis or Ligament tears.

6. Pregnant Females only: : .6

Current single pregnancy. o o .

Current single pregnancy with previous CS delivery. o o .

Current multiple pregnancy. o o .

Expected delivery date: :

Employee and dependents’ details that need to be added

(Please declare whether there is a medical condition for you or any family member) ( )

Hospital Name Condition Mobile No. Ht. (cm) Wt. (kg) ID# Relationship Gender Employee / Dependent Name

2176680730 Employee Male Moniru Zzaman Abdu Rashid 19

Undertaking

· I hereby undertake that all above information are correct and the acceptance of my ·
enrolment will be on the basis of such information and that (insurance company
name) has the right to contact the hospital(s) I deal with to collect any medical
information needed to assess the risk(s).
· I agree that (insurance company name) has the right to reject the coverage/claims in ·
full in case of no declaration of any cases prior to the contractual date or before
enrolling or adding a new Insured during the contract.
· I hereby confirm reading and understanding all points presented in this form and I
agree that not marking any case is understood as “Nothing requires declaration” and I ·
sign on these basis.
· Failure to fill the weight and height information will result in refusal to cover the cost of ·
obesity surgery.
Entity Stamp Employee Signature Date

09/06/2021
·  Upon renewal of the policy, the insurer shall not request a declaration form for any insured who has been insured for 11 · 
.
months.
·  The insurer is not eligible to request a medical declaration form for newborns when they are added to the existing health . · 
insurance policy. . · 
·  If you need to add more dependents, an additional form should be filled. . · 
·  It is illegal to sign this form by the employer instead of the employee.
Dear Insured: :
Please Fill out the form correctly for the purpose of pricing and to ensure that you
receive health care services as required according to your unfied policy benefit. .

Addition ¨ New þ
Employee Name: Nasir Uddin Gias Uddin : Entity Name: Saudi Efforts Contracting Company :
Gender: Male : Nationality: Bangladesh : Policy No. / Cr No.: 1010337564 :
ID No: 2234935175 : Mobile No: 0562002798 : Marital Status: Married þ Single ¨ :

Con. Please declare any of below cases for yourself or any of

No / Yes /
No. your dependents by marking ü under the word (Yes): : ü
1. Any hospital admission during the last 12 months. o o 12 .1
2. Have you been diagnosed with any of the following chronic diseases : .2
limited to:
Autism, Benign Tumor, Cancer, Heart Diseases, Chronic Hepatitis C, o o
Gallstones, Kidney failure, Urinary tract stones, thyroid goiter, Cysts,
fibroid uterus, Hernias, autoimmune diseases or Multiple sclerosis.
3. Have you been diagnosed with any of the following congenital disorder
or hereditary diseases limited to:
o o : .3

Cerebral palsy, Sickle cell disorder, Thalassemia, hemophilia, metabolic

diseases, Hydrocephalus, spinal muscle atrophy, genital malformations,
Chromosomal abnormalities, Gaucher’s disease, G6PD Deficiency,
cystic fibrosis, hemochromatosis, Wilson disease, Polycystic Kidney
Disease.

4. Have you been diagnosed with any of the following eye o o : .4

diseases limited to: .
Cataract, Glaucoma, Corneal diseases or Retinal diseases.
5. Have you been diagnosed with any of the following bone diseases o o : .5
limited to:
Vertebral disc prolapse, Scoliosis, Arthritis or Ligament tears.

6. Pregnant Females only: : .6

Current single pregnancy. o o .

Current single pregnancy with previous CS delivery. o o .

Current multiple pregnancy. o o .

Expected delivery date: :

Employee and dependents’ details that need to be added

(Please declare whether there is a medical condition for you or any family member) ( )

Hospital Name Condition Mobile No. Ht. (cm) Wt. (kg) ID# Relationship Gender Employee / Dependent Name

2234935175 Employee Male Nasir Uddin Gias Uddin 20

Undertaking

· I hereby undertake that all above information are correct and the acceptance of my ·
enrolment will be on the basis of such information and that (insurance company
name) has the right to contact the hospital(s) I deal with to collect any medical
information needed to assess the risk(s).
· I agree that (insurance company name) has the right to reject the coverage/claims in ·
full in case of no declaration of any cases prior to the contractual date or before
enrolling or adding a new Insured during the contract.
· I hereby confirm reading and understanding all points presented in this form and I
agree that not marking any case is understood as “Nothing requires declaration” and I ·
sign on these basis.
· Failure to fill the weight and height information will result in refusal to cover the cost of ·
obesity surgery.
Entity Stamp Employee Signature Date

09/06/2021
·  Upon renewal of the policy, the insurer shall not request a declaration form for any insured who has been insured for 11 · 
.
months.
·  The insurer is not eligible to request a medical declaration form for newborns when they are added to the existing health . · 
insurance policy. . · 
·  If you need to add more dependents, an additional form should be filled. . · 
·  It is illegal to sign this form by the employer instead of the employee.
Dear Insured: :
Please Fill out the form correctly for the purpose of pricing and to ensure that you
receive health care services as required according to your unfied policy benefit. .

Addition ¨ New þ
Employee Name: Nazrul Islam : Entity Name: Saudi Efforts Contracting Company :
Gender: Male : Nationality: Bangladesh : Policy No. / Cr No.: 1010337564 :
ID No: 2429087527 : Mobile No: 0562002798 : Marital Status: Married ¨ Single þ :

Con. Please declare any of below cases for yourself or any of

No / Yes /
No. your dependents by marking ü under the word (Yes): : ü
1. Any hospital admission during the last 12 months. o o 12 .1
2. Have you been diagnosed with any of the following chronic diseases : .2
limited to:
Autism, Benign Tumor, Cancer, Heart Diseases, Chronic Hepatitis C, o o
Gallstones, Kidney failure, Urinary tract stones, thyroid goiter, Cysts,
fibroid uterus, Hernias, autoimmune diseases or Multiple sclerosis.
3. Have you been diagnosed with any of the following congenital disorder
or hereditary diseases limited to:
o o : .3

Cerebral palsy, Sickle cell disorder, Thalassemia, hemophilia, metabolic

diseases, Hydrocephalus, spinal muscle atrophy, genital malformations,
Chromosomal abnormalities, Gaucher’s disease, G6PD Deficiency,
cystic fibrosis, hemochromatosis, Wilson disease, Polycystic Kidney
Disease.

4. Have you been diagnosed with any of the following eye o o : .4

diseases limited to: .
Cataract, Glaucoma, Corneal diseases or Retinal diseases.
5. Have you been diagnosed with any of the following bone diseases o o : .5
limited to:
Vertebral disc prolapse, Scoliosis, Arthritis or Ligament tears.

6. Pregnant Females only: : .6

Current single pregnancy. o o .

Current single pregnancy with previous CS delivery. o o .

Current multiple pregnancy. o o .

Expected delivery date: :

Employee and dependents’ details that need to be added

(Please declare whether there is a medical condition for you or any family member) ( )

Hospital Name Condition Mobile No. Ht. (cm) Wt. (kg) ID# Relationship Gender Employee / Dependent Name

2429087527 Employee Male Nazrul Islam 21

Undertaking

· I hereby undertake that all above information are correct and the acceptance of my ·
enrolment will be on the basis of such information and that (insurance company
name) has the right to contact the hospital(s) I deal with to collect any medical
information needed to assess the risk(s).
· I agree that (insurance company name) has the right to reject the coverage/claims in ·
full in case of no declaration of any cases prior to the contractual date or before
enrolling or adding a new Insured during the contract.
· I hereby confirm reading and understanding all points presented in this form and I
agree that not marking any case is understood as “Nothing requires declaration” and I ·
sign on these basis.
· Failure to fill the weight and height information will result in refusal to cover the cost of ·
obesity surgery.
Entity Stamp Employee Signature Date

09/06/2021
·  Upon renewal of the policy, the insurer shall not request a declaration form for any insured who has been insured for 11 · 
.
months.
·  The insurer is not eligible to request a medical declaration form for newborns when they are added to the existing health . · 
insurance policy. . · 
·  If you need to add more dependents, an additional form should be filled. . · 
·  It is illegal to sign this form by the employer instead of the employee.
Dear Insured: :
Please Fill out the form correctly for the purpose of pricing and to ensure that you
receive health care services as required according to your unfied policy benefit. .

Addition ¨ New þ
Employee Name: Sikindar Shaik Kareemulla : Entity Name: Saudi Efforts Contracting Company :
Gender: Male : Nationality: India : Policy No. / Cr No.: 1010337564 :
ID No: 2400745457 : Mobile No: 0562002798 : Marital Status: Married ¨ Single þ :

Con. Please declare any of below cases for yourself or any of

No / Yes /
No. your dependents by marking ü under the word (Yes): : ü
1. Any hospital admission during the last 12 months. o o 12 .1
2. Have you been diagnosed with any of the following chronic diseases : .2
limited to:
Autism, Benign Tumor, Cancer, Heart Diseases, Chronic Hepatitis C, o o
Gallstones, Kidney failure, Urinary tract stones, thyroid goiter, Cysts,
fibroid uterus, Hernias, autoimmune diseases or Multiple sclerosis.
3. Have you been diagnosed with any of the following congenital disorder
or hereditary diseases limited to:
o o : .3

Cerebral palsy, Sickle cell disorder, Thalassemia, hemophilia, metabolic

diseases, Hydrocephalus, spinal muscle atrophy, genital malformations,
Chromosomal abnormalities, Gaucher’s disease, G6PD Deficiency,
cystic fibrosis, hemochromatosis, Wilson disease, Polycystic Kidney
Disease.

4. Have you been diagnosed with any of the following eye o o : .4

diseases limited to: .
Cataract, Glaucoma, Corneal diseases or Retinal diseases.
5. Have you been diagnosed with any of the following bone diseases o o : .5
limited to:
Vertebral disc prolapse, Scoliosis, Arthritis or Ligament tears.

6. Pregnant Females only: : .6

Current single pregnancy. o o .

Current single pregnancy with previous CS delivery. o o .

Current multiple pregnancy. o o .

Expected delivery date: :

Employee and dependents’ details that need to be added

(Please declare whether there is a medical condition for you or any family member) ( )

Hospital Name Condition Mobile No. Ht. (cm) Wt. (kg) ID# Relationship Gender Employee / Dependent Name

2400745457 Employee Male Sikindar Shaik Kareemulla 22

Undertaking

· I hereby undertake that all above information are correct and the acceptance of my ·
enrolment will be on the basis of such information and that (insurance company
name) has the right to contact the hospital(s) I deal with to collect any medical
information needed to assess the risk(s).
· I agree that (insurance company name) has the right to reject the coverage/claims in ·
full in case of no declaration of any cases prior to the contractual date or before
enrolling or adding a new Insured during the contract.
· I hereby confirm reading and understanding all points presented in this form and I
agree that not marking any case is understood as “Nothing requires declaration” and I ·
sign on these basis.
· Failure to fill the weight and height information will result in refusal to cover the cost of ·
obesity surgery.
Entity Stamp Employee Signature Date

09/06/2021
·  Upon renewal of the policy, the insurer shall not request a declaration form for any insured who has been insured for 11 · 
.
months.
·  The insurer is not eligible to request a medical declaration form for newborns when they are added to the existing health . · 
insurance policy. . · 
·  If you need to add more dependents, an additional form should be filled. . · 
·  It is illegal to sign this form by the employer instead of the employee.
Dear Insured: :
Please Fill out the form correctly for the purpose of pricing and to ensure that you
receive health care services as required according to your unfied policy benefit. .

Addition ¨ New þ
Employee Name: Mohammad Anamul Hoque Sarker : Entity Name: Saudi Efforts Contracting Company :
Gender: Male : Nationality: Bangladesh : Policy No. / Cr No.: 1010337564 :
ID No: 2427612714 : Mobile No: 0562002798 : Marital Status: Married ¨ Single þ :

Con. Please declare any of below cases for yourself or any of

No / Yes /
No. your dependents by marking ü under the word (Yes): : ü
1. Any hospital admission during the last 12 months. o o 12 .1
2. Have you been diagnosed with any of the following chronic diseases : .2
limited to:
Autism, Benign Tumor, Cancer, Heart Diseases, Chronic Hepatitis C, o o
Gallstones, Kidney failure, Urinary tract stones, thyroid goiter, Cysts,
fibroid uterus, Hernias, autoimmune diseases or Multiple sclerosis.
3. Have you been diagnosed with any of the following congenital disorder
or hereditary diseases limited to:
o o : .3

Cerebral palsy, Sickle cell disorder, Thalassemia, hemophilia, metabolic

diseases, Hydrocephalus, spinal muscle atrophy, genital malformations,
Chromosomal abnormalities, Gaucher’s disease, G6PD Deficiency,
cystic fibrosis, hemochromatosis, Wilson disease, Polycystic Kidney
Disease.

4. Have you been diagnosed with any of the following eye o o : .4

diseases limited to: .
Cataract, Glaucoma, Corneal diseases or Retinal diseases.
5. Have you been diagnosed with any of the following bone diseases o o : .5
limited to:
Vertebral disc prolapse, Scoliosis, Arthritis or Ligament tears.

6. Pregnant Females only: : .6

Current single pregnancy. o o .

Current single pregnancy with previous CS delivery. o o .

Current multiple pregnancy. o o .

Expected delivery date: :

Employee and dependents’ details that need to be added

(Please declare whether there is a medical condition for you or any family member) ( )

Hospital Name Condition Mobile No. Ht. (cm) Wt. (kg) ID# Relationship Gender Employee / Dependent Name

2427612714 Employee Male Mohammad Anamul Hoque Sarker 23

Undertaking

· I hereby undertake that all above information are correct and the acceptance of my ·
enrolment will be on the basis of such information and that (insurance company
name) has the right to contact the hospital(s) I deal with to collect any medical
information needed to assess the risk(s).
· I agree that (insurance company name) has the right to reject the coverage/claims in ·
full in case of no declaration of any cases prior to the contractual date or before
enrolling or adding a new Insured during the contract.
· I hereby confirm reading and understanding all points presented in this form and I
agree that not marking any case is understood as “Nothing requires declaration” and I ·
sign on these basis.
· Failure to fill the weight and height information will result in refusal to cover the cost of ·
obesity surgery.
Entity Stamp Employee Signature Date

09/06/2021
·  Upon renewal of the policy, the insurer shall not request a declaration form for any insured who has been insured for 11 · 
.
months.
·  The insurer is not eligible to request a medical declaration form for newborns when they are added to the existing health . · 
insurance policy. . · 
·  If you need to add more dependents, an additional form should be filled. . · 
·  It is illegal to sign this form by the employer instead of the employee.