GROUP MEDICAL INSURANCE PROPOSAL FORM GROUP MEDICAL INSURANCE PROPOSAL FORM

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1 Call us: Allid Cooprativ Isurac Group (ACIG) شركة املجموعة املتحدة للتاأمني التعاوين ) أ سيج( GROUP MEDICAL INSURANCE GROUP MEDICAL INSURANCE

2 Clit Dtails: - GROUP MEDICAL INSURANCE PROPOSALFORM Plas complt this form usig CAPITAL LETTERS ad by tickig th rlvat boxs Compay Nam Busiss Activity / Idustry Cotact Prso Idustrial Clrical Costructio & Cotractig Trasportatio Othrs (plas spcify)... C.R No. Sposor No. Positio Tl No. Fax No. Postal Addrss Brokr (if ay):..(oly SAMA-approvd brokrs ar prmittd) Plas complt th tabls st out i Axur B. Also plas complt th summary tabls which follow with th umbr of bficiaris fallig withi ach sub-catgory whr th umbr of bficiaris is tak to ma th umbr of mploys ad ligibl dpdts currtly withi th compay or group. Eligibility for covr is dfid i li with th ruls of th CCHI. Th ligibility critria ar st out i Axur A of this Proposal Form. Ag Brackt Yars Employ Fmal Employ Childr Employ Fmal Employ Childr Employ Fmal Employ Childr Employ Fmal Employ Childr > 65 Total What is th avrag ag of your mploys?... Natioalitis Employ Fmal Empl oy Childr Em ploy Fmal Employ Childr Employ Fmal Employ Childr Employ Fmal Employ Childr Saudi's Arabs Asias Wstr rs TOTAL

3 Employ Fmal Employ Childr Employ Fmal Employ Childr Employ Fmal Employ Childr Employ Fmal Employ Childr Riyadh & Ctral Provic Jddah & Wstr Provic Dammam & Eastr Provic TOTAL Prst Arragmt: Currt Isurr (if Isurd): Expiry dat: Icptio dat of currt yar of covr: Icptio dat of first yar of covr with currt isurr: If you currtly ar isurd by aothr isurac compay plas provid th raso(s) for skig to chag your isurac compay. Is I-Hous Cliic i opratio Ys No locatios: - Expric: Plas provid us with th summary of your claims xpric for th last 3 yars as st out blow. Yar Mmbrs Mmbrs Mmbrs Mmbrs I-patit Yar Mmbrs Mmbrs Mmbrs Mmbrs

4 Additioal Iformatio: For ach of th past thr yars plas idicat how may mploys hav lft your mploymt ad how may w mploys hav b appoitd. Plas provid this iformatio for ach class of covr that is rlvat i.. VIP, A, B, ad C: Is thr workm compsatio covr or group lif & disability isurac i plac? If ys, hav thr b ay claims udr this covr for ach of th last thr yars. Plas provid a schdul with dtails o ach claim i.. Nam of claimat, Dat of claim, Typ of claim (Dath, Disability tc), of claim... Plas provid dtails, (i.. Nam of claimat, Employ or Dpdt, Gdr, Ag, Natioality, Caus of claim, of claim), of th t costlist mdical claims arisig from your mploys or o of thir dpdts for ach of th last thr yars Ar you awar of ay mploys which hav b admittd to hospital i th last moth or which will b admittd to hospital withi th xt two moths from th dat of this applicatio? If ys, plas provid dtails of th rasos for th hospital admissios Ar you awar of ay mploys or dpdts of mploys who ar chroically ill? If ys, plas provid dtails Ar ay of your mploys currtly o sick lav? If ys, plas provid dtails... Hav ay of your mploys b o sick lav for logr tha two work wks durig th prvious yar? If ys, plas provid dtails Ar ay of your mploys or thir ligibl dpdts prgat at this poit i tim? If ys, plas provid dtails... Stadard Covrag: - Th Scop of covr will b sam for all classs as pr th CCHI stadard policy. Howvr, th mmbrs udr ach of th classs will b assigd VIP, A, B & C srvic providrs rspctivly as pr ACIG s classificatios of providrs. (Plas fid appdd to this proposal th lists of providrs.) Basic Covr Typ Aual Limit SR 500,000 SR 500,000 SR 500,000 SR 500,000 Pr-xistig & Chroic Covrd Covrd Covrd Covrd Co-Isurac 20% Max SR % Max SR % Max SR % Max SR 100 Outpatit Covrd Covrd Covrd Covrd Ipatit Covrd Covrd Covrd Covrd Itsiv Car Uit Covrd Covrd Covrd Covrd Matrity Complicatios Covrd Covrd Covrd Covrd

5 Dtal Covr Typ Cosultatio, Fillig, X-ray, Extractio, Root Caal Tratmt & Gum Ifctio Tratmt Mdicis Covrd Covrd Covrd Covrd Sub Limit SR 2,000 SR 2,000 SR 2,000 SR 2,000 Co-Isurac 20% Max SR % Max SR % Max SR % Max SR 100 Optical Covr Typ Optical Aids Covrd Covrd Covrd Covrd Sub Limit SR 400 SR 400 SR 400 SR 400 Co-Isurac 20% Max SR % Max SR % Max SR % Max SR 100 Matrity Covr Typ At-Natal Car, Normal Dlivry, Casaria, Abormal Dlivry, Miscarriag, Lgal Abortio ad o post-atal car Covrd Covrd Covrd Covrd Sub Limit SR 15,000 SR 15,000 SR 15,000 SR 15,000 Waitig Priod Nil Nil Nil Nil Co-Isurac 20% Max SR % Max SR % Max SR % Max SR 100 Applicat's Dclaratios: - I / W cofirm th abov mtiod iformatio is corrct to th bst of my/our kowldg ad blif ad shall form th basis of isurac covr. I/W also udrstad that th isurac covr is compulsory for all our mploys ad thir ligibl dpdts ad our bst davours will b usd to sur that all our mploys ad thir ligibl dpdts will rol for th compulsory covr. I / W udrstad that ay odisclosur of matrial facts ad/or ay brach of good faith o my/our part will provid th right to ALLIED COOPERATIVE INSURANCE GROUP to cacl th cotract at ay tim durig th priod of isurac covr. Nam: Sigatur: Dat: Positio: Stamp: Dat Submittd:.... Dat Rcivd by ACIG:

6 Allid Cooprativ Isurac Group (ACIG) شركة املجموعة املتحدة للتاأمني التعاوين ) أ سيج( GROUP MEDICAL INSURANCE

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