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Oman New Health Application Form
Oman New Health Application Form
Application Form
Important Information
Kindly complete the questions on this form in BLOCK CAPITALS and tick the relevant boxes. It is important that you provide the following information
accurately so that we can process your application accordingly. This application must be completed in the Policy Holder or Insured Member’s own
handwriting (over 18 years old). If you need to make a correction, please highlight the change and add the date on it. For full details of the policy’s terms
and conditions, please refer to the table of benefits and membership handbook, available from AXA representative upon your request. We look forward to
welcoming you as a member of AXA Insurance (Gulf) B.S.C. (c).
*If you have any questions when completing this form, please contact your AXA sales team representative.
n It is essential that you provide the complete information before you sign on your medical application form and your medical health declaration.
n This form must be received by AXA Gulf within (30 days) from the declaration date. If we receive this form after 30 days from the signed declaration
date, or with incomplete information, we will not be able to register your details and enrol you into the Health Insurance plan.
n It is advisable that you fill in your form with an up to date medical history before you sign and date this form.
n Claims will not be payable if you do not fully disclose any facts which could influence our assessment of this application and if you are in any doubt as
to whether any facts, you should disclose them.
n You are advised to keep a record of all information you disclose to us in connection with this application, including letters
n Medical information will be kept confidential. Personal data collected from you and your family will be used by AXA Gulf to process your claims,
administer your policy and may be used to detect and prevent fraud or improper claims. It will only be disclosed to those involved with your treatment
or care and, if applicable, to any person or organisation who may be responsible for meeting your treatment expenses.
n All membership documents and confirmation of how we deal with any claim you may make will be sent to the principal member.
n In the interest of continuously improving our service; your calls will be recorded and may be monitored.
n Prior to signing the application, please make sure that you have read, understood and agreed to the policy terms and conditions.
Policy holder details (please keep us informed of any change in your address)
First name: Middle name:
Address:
Telephone number: Country Code Area code Number Mobile number: Country Code Area code Number
Occupation: Salary band: Less than OMR 400 More than OMR 400
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Your partner and family members (husband/wife & children to be insured with AXA)
Nationality/ Emirates ID Place of Visa
Title Name Relationship Sponsor Date of birth
passport number Number issuance
Wife/Husband/
DD/MM/YYYY
Son/Daughter
Wife/Husband/
DD/MM/YYYY
Son/Daughter
Wife/Husband/
DD/MM/YYYY
Son/Daughter
Wife/Husband/
DD/MM/YYYY
Son/Daughter
Wife/Husband/
DD/MM/YYYY
Son/Daughter
Section A: Please answer all questions below and if any of them is answered with “yes”, provide details in section B:
Name
Height (cm)
Weight (kg)
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Section B. Please provide details of all questions answered yes in the previous section:
*Chronic illness: a condition with one or more of the following criteria: last 3 months or more, leaves residual disability, is caused by non-reversible
pathological alteration, requires special training of the patient for rehabilitation, or may require long period of supervision or observation, e.g. diabetes
mellitus, hypertension, coronary artery disease etc.
*Pre-existing condition: an illness or health condition that was known and existed prior to submitting the application.
I understand that any change on my plan benefits which upgrades or downgrades my Health Insurance plan would only be possible at the time of renewal
subject to AXA Gulf’s acceptance, the completion of a new application form in addition to any other forms or reports that may be requested by AXA Gulf. I
understand and give explicit consent that any sensitive health and other information I may provide about myself will be used, stored, transferred and/or
disclosed by AXA, its agents, associated companies, other insurers, regulators, industry and public bodies (including the police) and agencies to process
this insurance and any other insurance, to handle claims and prevent fraud which may involve the transfer of such information to other countries.
AXA has taken steps to ensure that your information is held securely. You have the right to access your personal data held by AXA. If you believe that your
personal data held by AXA is inaccurate you have the right to ask for this to be rectified.
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