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IGI INSURANCE LTD.

- HEALTH INSURANCE DEPARTMENT


7TH FLOOR, THE FORUM, SUITE NOS. 701-713, G-20,
BLOCK-9, KHAYABAN-E-JAMI, CLIFTON, KARACHI.
UAN: 111-234-234, FAX: 92-21-35301772.

HEALTH DECLARATION FORM

Employee’s Name: _____________________________________________ Date of Birth: ________________________


Employee’s Designation: _____________________________________________ CNIC No: ________________________
Company: _____________________________________________ City: ________________________
Residence Address: _____________________________________________ Cell No: ________________________
______________________________________________ Land line: ________________________

FAMILY MEMBERS TO BE COVERED:


RELATIONSHIP WITH DATE OF BIRTH
NAME
YOU (dd/mm/yyyy)
1. SELF
2. SPOUSE
3. CHILD
4. CHILD
5. CHILD

6. CHILD
7. CHILD

IMPORTANT: Please ensure that all questions are answered YES or NO. You can attach prescriptions/supporting
documents explaining any condition with this form.
DESCRIPTION YES (√) NO (√)
A) Have you suffered or any member of your family (wife/children/parent) suffered / expired due to any of the
following? (Please tick the relevant condition)?
1) Any Form of Cancer 2) Heart Disease/Disorder 3) Diabetes Mellitus 4) Stroke / Paralysis 5) Kidney … …
Disease 6) Abnormal Blood Pressure 7) Liver Disease 8) COPD/Asthma 9) High Cholesterol
10) Blood Disorder 11) Any Form of Hepatitis 12) Smoking or Any disease not mentioned here.
B) Have you or any member your family to be covered been admitted to a hospital in the last 5 years due to any … …
disease/surgery/investigations?
C) Have you or any member of your family to be covered consulted a specialist doctor within the past 5 years?
If yes, give details of the illness/treatment. … …
D) Are you or your spouse pregnant? If yes, state months_____________________ … …
E) Have past confinements, if any, resulted in complications or Caesarian Section? … …
F) Is your spouse already enjoying medical facility from any other organization? … …

If you have answered ‘YES’ to any of the above questions, please provide the details below. Use your
prescriptions/investigations/extra sheets if required.
Date & Duration of Name/Address of attending
Name Medical condition Procedure/Result
Treatment doctor/hospital

DECLARATION: I hereby declare that what has been stated above is true and complete to the best of my knowledge and belief and
I have not withheld any information. I hereby authorize any hospital, physician or surgeon who has attended me or my family to
furnish to the IGI Health Insurance, with any information they may require concerning our medical history or examinations.

FOR EMPLOYER’S USE ONLY

Signature of the Employee for Self & on behalf of family, if being covered Plan for Coverage :
Effective Date (Date of
Date : ___________________________ inclusion in the Policy) :