GROUP HEALTH INSURANCE ACCEPTANCE FORM. New Customer Number of Customer Group Number Of Customer Policy Number

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1 GROUP HEALTH INSURANCE ACCEPTANCE FORM Clred area will be filled by Anadlu Sigrta / The Agent. Cde Number f Agent Cde Number f Sub-Agent Cde f Staff New Custmer Number f Custmer Grup Number Of Custmer Plicy Number It will be adequate t be filled and signed nly ne applicatin frm by the persnnel n behalf f his/her dependants t be insured. In this frm, it is t be declared crrect and cmplete infrmatin. In case f any incmplete and incrrect statements, Anadlu Annim Türk Sigrta Şirketi has a right nt t pay any indemnity amunt r/and t cancel the plicy accrding t the General Principles f Health Insurance. THE BLANK FOR DATE BELOW WILL BE FILLED OUT BY AN AUTHORIZED REPRESENTATIVE OF THE FIRM ON BEHALF OF THE PERSONNEL AND / OR THE FAMILY MEMBERS TO BE TAKEN WITHIN THE SCOPE OF POLICY AFTERWARDS. Cmmencement date f grup health insurance plicy f persnnel and/r family member is././. Please sign ne f the chices belw. This acceptance frm is submitted fr the first applicatin f persnnel and family members t Anadlu Annim Türk Sigrta Şirketi. This acceptance frm is filled ut fr additin f spuse and / r children f the persnnel t grup health insurance plicy. The persnnel himself is within the scpe f plicy. (If yu mark this chice, please state the name f the persnnel) 1. Staff Inf: Title f Yur Cmpany Department / Yur Prfessinal Title The date f Entrance Number T Yur Cmpany Office Phne Civil Status f Children././. Married (fr.) Single Widw T.R Identity Number* Tax Identity Number ** Tax Administratin *Please state the number if there is a T.R Identity Number that cntains 11 digits in yur identity card. If nt, please DO NOT STATE yur identity serial number; skip this part. **Accrding t general ntificatin regarding Tax Identity Number published in the Official Jurnal, determinatin f tax idenditiy number is bligatry t issue insurance plicy since Turkish citizens living abrad fr mre than six mnths d nt have t ntify their tax identity number. Hwever, it is required t attach the cpy f their passprt r residence/wrking permit t the applicatin frm.

2 Adress(Hme): Adress: Village/District Street Avenue Name f Apartment Number f Apartment Number f Flat Flr Zip Cde Quarter Cunty City Phne Mbile Phne Adress (Office): Adress: Village/District Street Avenue Name f Apartment Khan Bazaar Passage Independent Number f Apartment Khan Bazaar Passage Independent Number f Flat Flr Zip Cde Quarter Cunty City Phne Mbile Phne 2. Bank Accunt Inf: Please state yur bank accunt number that yu want us t pay the invice f yur health expenses yu send t ur Cmpany. (Stating yur İş Bankası accunt number, if exists, will accelerate yur prcedure). Name f the Bank Name f The Branch Accunt Number

3 3. Infrmatin Abut Persnnel and Family Members t be Insured: Gender Date f Birth Height / Weight Occupatin Persnnel M F../../ cm/ kg Spuse M F../../ cm/ kg 4. In this part, please give infrmatin abut yur and any f yur family members previus grup health insurance plicy. (Please write als abut INDIVIDUAL health insurance plicy yu and any f yur family members have frm anther Insurance Cmpany). In yur present cmpany, have yu ever been insured within the scpe f grup health insurance in the past? If yur answer is YES Previus Insurance Cmpany Original Cmmencemet Date f the Plicy Are the riginal cmmencement date f yur grup health insurance plicy and yur family members grup health insurance plicy identical? If yur answer is NO; please state the name, surname and riginal cmmencemet date f yur family members t be cvered within the scpe f grup health insurance. HEALTH DECLARATION 1. During the last 1 year, have yu and/r any f yur family members t be insured been examined by a physician? Have yu and / r any f yur family members t be insured had any health cmplaint even if it is nt diagnsed and/r has any diagnstic test been perfrmed such as bld bichemistry, X-Ray, MR, Tmgraphy, Ultrasngraphy, Synthiagraphy, Endscphic Treatments, Mammgraphy etc.). If s, please state belw and / r send the results f the labratry tests with the applicatin frm. Disease Type f the Treatment First Diagnsis Date and Name f the Health Institutin

4 2. Have yu and/r any f yur family members t be insured undergne a surgery r an inpatient medicatin in the past? (If s, please send the discharge summary and/r the peratin reprt and the results f the diagnstic prcedures by attaching them t the applicatin frm. The Name f the Operatin The Name f the In-Patient Treatment Withut Operatin The Name f the Hspital and the Physician Date /../ /../ 3. Have yu and/r any f yur family members t be insured ever suffered frm any f the diseases stated belw, been examined and received medical treatment? If s, please mark the fllwing diseases. Cardivascular Diseases ( ) Giter ( ) Hypertensin ( ) Hernia ( ) Diabetes ( ) Gastritis ( ) Canser ( ) Peptic Ulcer ( ) Rheumatism ( ) Gastrintestinal Bleeding ( ) Depressin ( ) Alchlism ( ) Shrtness f Breath ( ) Hemrrid ( ) Tuberculsis ( ) Gallblader Stnes ( ) Chrnic Brnchitis ( ) Breast Diseases ( ) Asthma ( ) Geneclgic Diseases ( ) Ovarian Cyst ( ) Myma ( ) Liver Disease ( ) Kidney Disease ( ) Urinary Tract Stnes ( ) Chrnic Waist and Neck Pain ( ) Anemia ( ) Neurlgical Diseases ( ) Chrnic Headache ( ) Lss f Hearing ( ) Chrnic Urinary and Diarhea ( ) Chrnic Nasal Cngestin ( ) Incntinance ( ) Sinusitis ( ) Recent Traumatism/Accident ( ) Bld Diseases ( ) 4. D yu and/r any f yur family members t be insured have any health prblem presently, get medical treatment, take any medicine cntinuusly, have any medical cmplaint which is s serius t require an peratin? Are there any pregnant females in yur family? Disease Kind f Treatment (Medicine Operatin) First Diagnsis Date and Name f the Health Institutin The scpe f benefits prepared n the basis f yur declaratin and the detail infrmatin regarding the esence f claims stated in the General and Special Principles f Health Insurance and Clauses will be delivered t yu with yur plicy. If yu wish, yu can btain these infrmatin frm yur agent r frm Anadlu Annim Türk Sigrta Şirketi District Offices befre yur plicy is issued.

5 I declare and acknwledge that Anadlu Annim Türk Sigrta Şirketi may btain all kind f infrmatin and recrd abut my health status frm health institutins, physicians and third persns. I knw and acknwledge that this insurance plicy will nt cver expenses related t illnesses that are knwn t exist befre the cmmencement date f the plicy by me and my family members. I accept that this plicy cvers the claims within the limits stipulated in the table f benefits. I declare and acknwledge that filling this frm des nt mean t be insured by Anadlu Annim Türk Sigrta Şirketi and this plicy will be get int frce nly after the applicatin frm is accepted, plicy is issued and the premium is paid. As an applicant fr insurance, I declare that all the infrmatin I have given abut me and my family members t be insured are cmplete and true. I acknwledge that all the infrmatin in this applicatin frm and in the health declaratin is cmplete, true and cmpatible with reality and in case the ppsite is prved, I will abandn all the rights deriving frm health insurance cntract..... Date Signature Agent Clred area will be filled by Anadlu Sigrta / The Agent. Arranger Date-Hur Date Date Cntrller Signature / Cachet Signature / Cachet Signature / Cachet

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