UniTrust

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Salary

Insurance History

Member1

(in case answer is "Yes," specify reason)

Have you ever been accepted for life and/or health insurance on sub-standard terms?

Yes No

Have you ever been declined for life and/or health insurance?

Yes No

Extra Professional Activities

Member1

Do you want to be covered for all amateur sport activities? (if “Yes,” specify the most dangerous sport you currently practice or would intend to practice in the future) ?

Yes No

Do you ride motorcycles? (if “Yes,” specify if you require coverage for motorcycle accident) ?

Yes No

Specific Medical History

Member1

(if "Yes," specify diagnostic details, treatment received & recovery status)

Have you ever been diagnosed, treated or felt any disorder, pain or had any symptoms related to the:

Musculoskeletal & /or Connective Tissue System ?

Yes No

what was diagnosis ? when did it start ? what medications are you taking as well as dosage ? Treatment received,if so,please describe...

Cancer, Neoplasms, Tumors

Yes No

what was diagnosis ? when did it start ? what medications are you taking as well as dosage ? Treatment received,if so,please describe...

Blood & Blood Forming Organ Systems ?

Yes No

what was diagnosis ? when did it start ? what medications are you taking as well as dosage ? Treatment received,if so,please describe...

Digestive System ?

Yes No

what was diagnosis ? when did it start ? what medications are you taking as well as dosage ? Treatment received,if so,please describe...

Nervous System or Sense Organs ?

Yes No

what was diagnosis ? when did it start ? what medications are you taking as well as dosage ? Treatment received,if so,please describe...

Respiratory System ?

Yes No

what was diagnosis ? when did it start ? what medications are you taking as well as dosage ? Treatment received,if so,please describe...

Cardiovascular System ?

Yes No

what was diagnosis ? when did it start ? what medications are you taking as well as dosage ? Treatment received,if so,please describe...

Skin-SubcutaneousTissue ?

Yes No

what was diagnosis ? when did it start ? what medications are you taking as well as dosage ? Treatment received,if so,please describe...

Have you ever undergone surgery to remove a body organ or structure ?

Yes No

what was diagnosis ? when did it start ? what medications are you taking as well as dosage ? Treatment received,if so,please describe...

Are you HIV positive or have any medical condition or symptom indicative of HIV infection or AIDS ?

Yes No

what was diagnosis ? when did it start ? what medications are you taking as well as dosage ? Treatment received,if so,please describe...

Tested Positive for COVID 19 and recovered ?

Yes No

what was diagnosis ? when did it start ? what medications are you taking as well as dosage ? Treatment received,if so,please describe...

Tested Positive for COVID 19 and currently undergoing treatment. ?

Yes No

what was diagnosis ? when did it start ? what medications are you taking as well as dosage ? Treatment received,if so,please describe...

Self-isolated with symptoms on medical advice ?

Yes No

what was diagnosis ? when did it start ? what medications are you taking as well as dosage ? Treatment received,if so,please describe...

Endocrine, Nutritional, Metabolic and/or Immunity System?

Yes No

what was diagnosis ? when did it start ? what medications are you taking as well as dosage ? Treatment received,if so,please describe...

Genitourinary System?

Yes No

what was diagnosis ? when did it start ? what medications are you taking as well as dosage ? Treatment received,if so,please describe...

Family Medical History

Member1

Has any member of your family had symptoms or been diagnosed or received treatment for:

Inherited disorder or genetic disease ?

Yes No

what was diagnosis ? when did it start ? what medications are you taking as well as dosage ? Treatment received,if so,please describe...

Hemophilia ?

Yes No

what was diagnosis ? when did it start ? what medications are you taking as well as dosage ? Treatment received,if so,please describe...

Muscular Dystrophy ?

Yes No

what was diagnosis ? when did it start ? what medications are you taking as well as dosage ? Treatment received,if so,please describe...

Multiple Sclerosis ?

Yes No

what was diagnosis ? when did it start ? what medications are you taking as well as dosage ? Treatment received,if so,please describe...

Cancer ?

Yes No

what was diagnosis ? when did it start ? what medications are you taking as well as dosage ? Treatment received,if so,please describe...

Nervous Mental illness or disorders ?

Yes No

what was diagnosis ? when did it start ? what medications are you taking as well as dosage ? Treatment received,if so,please describe...

Nervous system and / or sense organ disease ?

Yes No

what was diagnosis ? when did it start ? what medications are you taking as well as dosage ? Treatment received,if so,please describe...

Illness of the cardiovascularsystem ?

Yes No

what was diagnosis ? when did it start ? what medications are you taking as well as dosage ? Treatment received,if so,please describe...

Diabetes ?

Yes No

what was diagnosis ? when did it start ? what medications are you taking as well as dosage ? Treatment received,if so,please describe...

Profile

Member1

Profile (if answer Yes is selected, specify details and numbers)

Do you smoke?

Yes No

Do you practice any kind of routineexercise?

Yes No

Do you undergo routine medical check-ups?

Yes No

How often do you consult a physician per year?

How many hours do you sleep per day?

How many hours do you work per day?

How many times do you travel peryear?

Do you drink alcohol (if yes, specify preferred type and daily/weekly consumption)

Yes No

Have you ever taken any drugs?

Yes No

Please pick the plan required

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Last Name

Phone

Email

Visa Holders from Emirates

Member's Schedule: All Family Members

(Main Applicant As No 1)

Member No

Name

Relation

Gender

DOB

Height(cm)

Weight(kg)

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