Transaction effective date ‫اﻟﺘﺎرﻳﺦ اﳌﻄﻠﻮب ﻟﺘﻨﻔﻴﺬ اﻟﻌﻤﻠﻴﺔ‬ ‫ﺑﺮﺟﺎء ارﺳﺎل ﻫﺬه اﻟﺼﻔﺤﺔ ﻋﻠﻰ اﻟﻳﺪ اﻟﻜو‬

Note: :‫ﻣﻼﺣﻈﺔ‬
Backdating transactions should ‫ﻳﺴﻤﺢ ﺑﺘﻨﻔﻴﺪ اﻟﻌﻤﻠﻴﺎت ﺑﺄﺗﺮ رﺟﻌﻲ ﻻ ﻳﺰﻳﺪ ﻋﻦ‬ MembershipEmail@bupa.com.sa
not excced 30 days period or 10 ‫ﻣﻘﺪم‬ ‫ أﻳﺎم‬10 ‫ أو‬Ë‫ ﻳﻮﻣ‬30 920 000 725 ‫أو ﻋﻠﻰ ﻓﺎﻛﺲ رﻗﻢ‬
days onward ً

Please Email it to
Contract Number ‫رﻗﻢ اﻟﻌﻘﺪ‬
MembershipEmail@bupa.com.sa
Company Name ‫اﺳﻢ اﻟﺸﺮﻛﺔ‬ Or fax this page to 920 000 725

:‫ اﺳﻢ ا‘ﻮل وﺗﻮﻗﻴﻌﻪ‬/‫ﺧﺘﻢ اﻟﺸﺮﻛﺔ أو اﳌﺆﺳﺴﺔ‬

Company Stamp / Authorized name and signature:
Transaction Type ‫ﻧﻮع اﻟﻌﻤﻠﻴﺔ‬
Note: :‫ﻣﻼﺣﻈﺔ‬ Please choose (fill in) one of the below transactions: :‫اﻟﺮﺟﺎء اﺧﺘﻴﺎر )ﺗﻈﻠﻴﻞ( اﻟﻌﻤﻠﻴﺔ اﳌﻄﻠﻮﺑﺔ‬
The request will not be accepted ‫ ﺣﺎل ﻋﺪم ﺗﻄﺎﺑﻖ‬¥ ‫ﻟﻦ ﻳﺘﻢ ﻗﺒﻮل اﻟﻄﻠﺐ‬ All the below options require additional documentation (refer to general rules in page 3). ‫ وﻳﺮﺟﻰ ﻗﺮاءة اﻻرﺷﺎدات‬3 ‫ ﺻﻔﺤﺔ‬¥ ‫ﺟﻤﻴﻊ اﻟﻌﻤﻠﻴﺎت أدﻧﺎه ﺗﺘﻄﻠﺐ ارﻓﺎق ﺑﻌﺾ اﻟﻮﺛﺎﺋﻖ )اﻟﺮﺟﺎء ﻗﺮاءة اﻟﻘﻮاﻋﺪ اﻟﻌﺎﻣﺔ‬
if the Signature and Stamp on this ‫اﻟﺘﻮﻗﻴﻊ واﳋﺘﻢ ﻣﻊ اﻟﺘﻮاﻗﻴﻊ وا¯ﺧﺘﺎم اﳌﺪرﺟﺔ‬ For any assistance on how to fill out the form, please read the guidelines in the following pages. .(‫ ا¯رﻗﺎم أدﻧﺎه‬°‫ اﻟﺼﻔﺤﺎت اﻟﺘﺎﻟﻴﺔ ﳌﻌﺮﻓﺔ ﻃﺮﻳﻘﺔ ﺗﻌﺒﺌﺔ اﻟﻨﻤﻮذج وﻣﻌﺎ‬¥ ‫اﳌﻮﺿﺤﺔ‬
form are not matched with the .‫ ﺳﺠﻼﺗﻨﺎ‬¥ ‫ اﻟﻨﻤﻮذج اﳋﺎص‬¥
approved ones in our records. Add new employee and dependent(s) ‫إﺿﺎﻓﺔ ﻣﻮﻇﻒ ﺟﺪﻳﺪ وﻋﺎﺋﻠﺘﻪ‬
Add new born ‫إﺿﺎﻓﺔ ﻣﻮﻟﻮد ﺟﺪﻳﺪ‬
(*) Mandatory Field. .‫)@( ﺣﻘﻞ إﻟﺰاﻣﻲ‬
Add dependent(s) of an insured employee ‫إﺿﺎﻓﺔ ﻋﺎﺋﻠﺔ ﻣﻮﻇﻒ ﻣﺆﻣﻦ‬
Replace card(s) ( lost Data correction) Employee Dependents ‫ﻟﻠﻌﺎﺋﻠﺔ‬ ‫ﻟﻠﻤﻮﻇﻒ‬ (‫ﺗﺼﺤﻴﺢ ﻣﻌﻠﻮﻣﺎت‬ ‫ﺑﺪل ﻓﺎﻗﺪ‬ ) ‫اﺳﺘﺒﺪال اﻟﺒﻄﺎﻗﺔ‬
Member Profession Member City ID No. ID Type ID Expiry Date ‫ﺗﺎرﻳﺦ اﻧﺘﻬﺎء اﻟﻬﻮﻳﺔ‬ ‫ﻧﻮع اﻟﻬﻮﻳﺔ‬ ‫رﻗﻢ اﻟﻬﻮﻳﺔ‬ ‫اﳌﺪﻳﻨﺔ‬ ‫اﳌﺴﻤﻰ اﻟﻮﻇﻴﻔﻲ‬
Stamp ‫ اﳋﺘﻢ‬Signature ‫اﻟﺘﻮﻗﻴﻊ‬
Date of Birth Member Type/Relation ‫اﻟﻌﻼﻗﺔ‬/‫ﻧﻮع اﻟﻌﻀﻮ‬ ‫ﺗﺎرﻳﺦ اﳌﻴﻼد‬
Re-activating ‫إﻋﺎدة ﺗﻔﻌﻴﻞ ﻋﻀﻮﻳﺔ ’ﺬوﻓﺔ‬
Delete an employee ( Dependents will be deleted automatically) Saudi Non Saudi ‫ﻏ– ﺳﻌﻮدي‬ ‫ﺳﻌﻮدي‬ (‫إﻟﻐﺎء اﳌﻮﻇﻒ )ﺳﻴﺘﻢ اﻟﻐﺎء ﺟﻤﻴﻊ اﳌﻌﺎﻟﲔ‬
Delete a dependent(s) Saudi/s Non Saudi/s ‫ﻏ– ﺳﻌﻮدي‬ ‫ﺳﻌﻮدي‬ ‫إﻟﻐﺎء ﻋﺎﺋﻠﺔ ﻣﻮﻇﻒ ﻣﺆﻣﻦ‬
Employee Upgrade or Downgrade (and dependents) ‫ﺗﻌﺪﻳﻞ درﺟﺔ ﺗﻐﻄﻴﺔ اﳌﻮﻇﻒ وﻋﺎﺋﻠﺘﻪ‬
Transfer to new Branch ‫اﻧﺘﻘﺎل اﳌﻮﻇﻒ إŸ ﻓﺮع آﺧﺮ‬

EMPLOYEE DETAILS ‫ﺑﻴﺎﻧﺎت اﳌﻮﻇﻒ‬

1. *Current membership No. (skip if new member) (‫ ﺣﺎﻟﺔ اﺿﺎﻓﺔ ﻣﻮﻇﻒ ﺟﺪﻳﺪ‬¥ ‫رﻗﻢ اﻟﻌﻀﻮﻳﺔ اﳊﺎ» )ﻏ– ﻣﻄﻠﻮب‬ 2. *Gender ‫اﳉﻨﺲ‬ F ‫أﻧﺜﻰ‬ M ‫ذﻛﺮ‬ 3. Employee No. ‫رﻗﻢ اﳌﻮﻇﻒ‬

4. *Name as per the ID (First - Middle - Last) (‫ اﻟﻠﻘﺐ‬- ‫ ا¯وﺳﻂ‬- ‫ اﻟﻬﻮﻳﺔ )ا¯ول‬/ ‫اﻻﺳﻢ ﺣﺴﺐ ا¶ﻗﺎﻣﺔ‬

5. *Date of Birth (Gregorian) (‫ﺗﺎرﻳﺦ اﳌﻴﻼد )ﺑﺎﳌﻴﻼدي‬ DD / MM / YYYY 6. *Requested Level Cover ‫درﺟﺔ اﻟﺘﻐﻄﻴﺔ اﳌﻄﻠﻮﺑﺔ‬

7. *ID No. ‫رﻗﻢ اﻟﻬﻮﻳﺔ‬ 8. *Sponsor ID ‫رﻗﻢ اﻟﻜﻔﻴﻞ‬ 9. *Nationality ‫اﳉﻨﺴﻴﺔ‬

10. *ID Type ‫ﻧﻮع اﻟﻬﻮﻳﺔ‬ 11. *ID Expiry Date ‫ﺗﺎرﻳﺦ اﻧﺘﻬﺎء اﻟﻬﻮﻳﺔ‬ 12. *Marital Status ‫اﳊﺎﻟﺔ ا¶ﺟﺘﻤﺎﻋﻴﺔ‬

13. *Branch Name ‫اﺳﻢ اﻟﻔﺮع‬ 14. Reason ‫اﻟﺴﺒﺐ‬ 15. Exit Date ‫ﺗﺎرﻳﺦ اﳋﺮوج‬ DD / MM /YYYY

16. *Member Occupation (‫اﳌﺴﻤﻰ اﻟﻮﻇﻴﻔﻲ )ﺣﺴﺐ ا¶ﻗﺎﻣﺔ‬ 17 *Member City ‫اﳌﺪﻳﻨﺔ‬ 18. *Mobile No. ‫رﻗﻢ اﳉﻮال‬

19. *National Address ‫اﻟﻌﻨﻮان اﻟﻮﻃﻨﻲ‬ *Building No. .‫رﻗﻢ اﳌﺒﻨﻲ‬ *Street Name. .‫* اﺳﻢ اﻟﺸﺎرع‬District Name. .‫اﺳﻢ اﳊﻲ‬

*City Name. .‫* اﺳﻢ اﳌﺪﻳﻨﺔ‬Zip Code. .‫* اﻟﺮﻣﺰ اﻟ¿ﻳﺪي‬Additional No. .¥‫* اﻟﺮﻣﺰ اﻻﺿﺎ‬Unit No. .‫رﻗﻢ اﻟﻮﺣﺪة‬

DEPENDANTS DETAILS ‫ﺑﻴﺎﻧﺎت اﻟﻌﺎﺋﻠﺔ‬

20. Current membership no 21. *Name as per the ID 22. *Date of Birth 23. *ID No. 24. *ID Type 25. *ID Expiry Date 26. *Marital Status 27. *Member City 28. *Nationality 29. *Relationship 30. *Gender 31. *Mobile No.
(skip if new member) (First - Middle - Last) ‫ﺗﺎرﻳﺦ اﳌﻴﻼد‬ ‫رﻗﻢ اﻟﻬﻮﻳﺔ‬ ‫ﻧﻮع اﻟﻬﻮﻳﺔ‬ ‫ﺗﺎرﻳﺦ اﻧﺘﻬﺎء اﻟﻬﻮﻳﺔ‬ ‫اﳊﺎﻟﺔ ا¶ﺟﺘﻤﺎﻋﻴﺔ‬ ‫اﳌﺪﻳﻨﺔ‬ ‫اﳉﻨﺴﻴﺔ‬ ‫ﺻﻠﺔ اﻟﻘﺮاﺑﺔ‬ ‫اﳉﻨﺲ‬ ‫رﻗﻢ اﳉﻮال‬
¥ ‫رﻗﻢ اﻟﻌﻀﻮﻳﺔ اﳊﺎ» )ﻏ– ﻣﻄﻠﻮب‬ ‫ اﻟﻬﻮﻳﺔ‬/‫اﻻﺳﻢ ﺣﺴﺐ ا¶ﻗﺎﻣﺔ‬
(‫ﺣﺎل اﺿﺎﻓﺔ ﺟﺪﻳﺪة‬ (‫ اﻟﻠﻘﺐ‬- ‫ ا¯وﺳﻂ‬- ‫)ا¯ول‬

I certify that the information given on this form and in any documents attached is correct, complete and accurate. I ‫ ﻫﺬا اﻟﻨﻤﻮذج وأي وﺛﻴﻘﺔ أﺧﺮى ﻣﺮﻓﻘﺔ ﺑﻬﻦ وإﻧﻨﻲ اﺗﻘﺒﻞ ﻣﺜﻞ ﻫﺬه ا¶ﺟﺮاءات وادرك أن ﺗﻘﺪﱘ أي ﻣﻌﻠﻮﻣﺎت ﺧﺎﻃﺌﺔ أو ﻣﻀﻠﻠﺔ‬¥ ‫ أﻗﺮ ﺑﺼﺤﺔ ﺟﻤﻴﻊ اﳌﻌﻠﻮﻣﺎت اﻟﻮارد أﻋﻼه‬:‫إﻗﺮار‬
understand that the information provided by me maybe verified and hereby consent to such verification activities. I also
understand that providing false or misleading information may result in canceling the membership and may be grounds for .‫ ﻟﻠﻤﺴﺄﻟﺔ اﻟﻘﺎﻧﻮﻧﻴﺔ‬Ë‫ﺳﻮف ﻳﺆدي إŸ اﻟﻐﺎء اﻟﻌﻀﻮﻳﺔ وﻗﺪ ﳝﺜﻞ أﺳﺎﺳ‬
any legal accountability.
1 / ١
Guidelines:
This section provides some guidelines on how to fill in page Depends on
transaction type; you get to fill in the necessary information that satisfies
our requirements. You can always call our membership team on 800 4400
555 for any clarifications during the working hours (9 am- 5 pm) Sun to Thu:
:‫إرﺷﺎدات ﺗﻌﺒﺌﺔ اﻟﻨﻤﻮذج‬
‫ان ﻗﺮاءة ﻫﺬه اﻻرﺷﺎدات و اﺗﺒﺎﻋﻬﺎ ﺑﺪﻗﺔ ﳝﻜﻨﻚ ﻣﻦ ﺗﻌﺒﺌﺔ اﻟﻄﻠﺐ ﺑﺸﻜﻞ ﺻﺤﻴﺢ ودﻗﻴﻖ ﲟﺎ ﻳﺘﻨﺎﺳﺐ ﻣﻊ‬
800 4400 555 ‫ ¯ي اﺳﺘﻔﺴﺎر ﳝﻜﻨﻜﻢ اﻻﺗﺼﺎل ﻋﻠﻰ ﺧﺪﻣﺎت اﻟﻌﻀﻮﻳﻪ رﻗﻢ‬.‫ﻣﺘﻄﻠﺒﺎت اﲤﺎم اﻟﻌﻤﻠﻴﺔ اﳌﻄﻠﻮﺑﺔ‬
:‫ ﻣﺴﺎء( ﻣﻦ ا¯ﺣﺪ اŸ ااﳋﻤﻴﺲ‬-5‫ ﺻﺒﺎﺣﺎ‬9) ‫ﺧﻼل ﺳﺎﻋﺎت اﻟﺪوام اﻟﺮﺳﻤﻲ‬

1. Transaction date, contract number and company name are mandatory ‫ ﺟﻤﻴﻊ‬¥ ‫ﻻﺑﺪ ﻣﻦ ﲢﺪﻳﺪ رﻗﻢ اﻟﻌﻘﺪ واﺳﻢ اﻟﺸﺮﻛﺔ ﻣﻊ ﺗﻮﺿﻴﺢ اﻟﺘﺎرﻳﺦ اﳌﻄﻠﻮب ﻟﺘﻨﻔﻴﺬ اﻟﻌﻤﻠﻴﺔ‬ .1
fields and must always be provided, regardless of the transaction type. .‫اﻟﻄﻠﺒﺎت أﻳﺎ ﻛﺎن ﻧﻮﻋﻬﺎ‬

2. Please refer to the below schedule and make sure you fill all the fields
corresponding to their numbers stated below: .‫اﻟﺮﺟﺎء اﻻﻃﻼع ﻋﻠﻰ اﳉﺪول اﻟﺘﺎ» ﻟﻠﺘﺄﻛﺪ ﻣﻦ ﺗﻌﺒﺌﺔ ﺟﻤﻴﻊ اﳊﻘﻮل اﳌﻄﻠﻮﺑﺔ ¶ﲤﺎم اﻟﻌﻤﻠﻴﺔ ﺑﻨﺠﺎح‬ .2

Transaction type Mandatory field Notes ‫ﻣﻼﺣﻈﺎت‬ ‫أرﻗﺎم اﳊﻘﻮل اﳌﻄﻠﻮﺑﺔ‬ ‫ﻧﻮع اﻟﻌﻤﻠﻴﺔ‬
number

Employee only: :‫ ﺣﺎﻟﺔ إﺿﺎﻓﺔ اﳌﻮﻇﻒ ﻓﻘﻂ‬¥

From 2 to 13 13 Ÿ‫ إ‬2 ‫ﻣﻦ‬
Then From 16-18 1٨ ¶‫ إ‬16 ‫ﺛﻢ ﻣﻦ‬
Employee and ‫ ﺣﺎل إﺿﺎﻓﺔ‬¥
Add new Employee 3 only if applicable ‫ ﺣﺎل ﺗﻮﻓﺮ ذﻟﻚ‬¥ 3 ‫اﺿﺎﻓﺔ ﻣﻮﻇﻒ ﺟﺪﻳﺪ وﻋﺎﺋﻠﺘﻪ‬
dependent: :‫اﻟﻌﺎﺋﻠﺔ واﳌﻮﻇﻒ‬
and Dependents
From 2 to 13 13 Ÿ‫ إ‬2 ‫ﻣﻦ‬
Then From 16-18 18 ¶‫ إ‬16 ‫ﺛﻢ ﻣﻦ‬
And ‫و‬
From 19 to 30 30 ¶‫ إ‬19 ‫ﻣﻦ‬

1-4-7-8 8-7-4-1
Add new born ‫اﺿﺎﻓﺔ ﻣﻮﻟﻮد ﺟﺪﻳﺪ‬
Then From 20 - 30 30 ¶‫ إ‬20 ‫ﺛﻢ ﻣﻦ‬

Add dependents of 1-4-7-8 8-7-4-1

an insured employee Then From 20 to 30 ‫اﺿﺎﻓﺔ ﻋﺎﺋﻠﺔ ﻣﻮﻇﻒ ﻣﺆﻣﻦ‬
30 ¶‫ إ‬20 ‫ﺛﻢ ﻣﻦ‬

The fields from (2 to 18

Ÿ‫ ا‬2 ‫ﻳﺘﻢ ﺗﻌﺒﺌﻪ اﳊﻘﻮل )ﻣﻦ‬
for employees or from
30 Ÿ‫ إ‬20 ‫ ﻟﻠﻤﻮﻇﻒ أو ﻣﻦ‬18
20 to 30 for
dependents) will be ‫ﻟﻠﻌﺎﺋﻠﺔ( ﺑﺤﺴﺐ اﻟﺴﺒﺐ‬
filled according to the 14 ‫ اﳊﻘﻞ‬¥ ‫اﳌﻮﺿﺢ‬
Replace cards 1 - 4 – 14 14 - 4 - 1 ‫اﺳﺘﺒﺪال اﻟﺒﻄﺎﻗﺔ‬
reason.
‫ اذا ﻛﺎن اﻟﺴﺒﺐ ﻫﻮ‬: ‫ﻣﺜﺎل‬
Example: if the reason
‫ اﺳﻢ اﳌﻮﻇﻒ‬¥ ‫ﺧﻄﺄ‬
is wrong Employee
2 ‫ﻓﻴﺠﺐ ﺗﻌﺒﺌﺔ اﳊﻘﻞ رﻗﻢ‬
name, field number 2
must be filled

For Employee: :‫ﻟﻠﻤﻮﻇﻒ‬

1 - 4 - 14 14 - 4 - 1
Re-activating :‫ﻟﻠﻤﻌﺎﻟﲔ‬ ‫اﻋﺎدة ﺗﻔﻌﻴﻞ ﻋﻀﻮﻳﺔ ’ﺬوﻓﺔ‬
For Dependents:
1 - 4 - 14 then 19 - 20 20 - 19 ‫ ﺛﻢ‬14 - 4 - 1

Dependents will be
Delete an employee 1 - 4 - 14 - 15 deleted automatically. Ë‫ﺳﻴﺘﻢ اﻟﻐﺎء اﳌﻌﺎﻟﲔ ﺗﻠﻘﺎﺋﻴ‬ 14 - 4 - 1 ‫ﺣﺬف ﻣﻮﻇﻒ‬

Delete Dependents 14 – 15 then 19 – 20 20 - 19 ‫ ﺛﻢ‬15 - 14 ‫اﻟﻐﺎء ﻋﺎﺋﻠﺔ ﻣﻮﻇﻒ ﻣﺆﻣﻦ‬

Employee upgrade ‫ﺗﻌﺪﻳﻞ درﺟﺔ ﺗﻐﻄﻴﺔ اﳌﻮﻇﻒ‬

1 - 4 - 6 - 14 14 - 6 - 4 - 1
or downgrade ‫وﻋﺎﺋﻠﺘﻪ‬

In field no. 13, only the

Transfer to a new ‫ﻳﺠﺐ ﻛﺘﺎﺑﺔ اﻟﻔﺮع اﳉﺪﻳﺪ‬
1 - 4 - 13 new branch name must 13 - 4 - 1 ‫اﻧﺘﻘﺎل اﳌﻮﻇﻒ اŸ ﻓﺮع آﺧﺮ‬
branch (13 ‫ ﺧﺎﻧﺔ رﻗﻢ‬¥ ) ‫ﻓﻘﻂ‬
be provided.

The below rules were designed in compliance with the Council of
Cooperative health Insurance (CCHI) and Saudi Arabian Monetary
Agency (SAMA):
General rules:
• Bupa covers Saudi nationals and members who are having valid
Iqama, valid resident visa and/or Business, Commercial / visa
(Bupa Arabia pre-approval is mandated to accept Business,
Commercial visa).
‫اﻟﻘﻮاﻋﺪ أدﻧﺎه وﺿﻌﺖ ﻟﺘﺘﻮاﻓﻖ ﻣﻊ اﻟﻼﺋﺤﺔ اﻟﺘﻨﻔﻴﺬﻳﺔ اﳌﻌﺪﻟﺔ ¸ﻠﺲ‬
:‫اﻟﻀﻤﺎن اﻟﺼﺤﻲ اﻟﺘﻌﺎو وﻣﺆﺳﺴﺔ اﻟﻨﻘﺪ اﻟﻌﺮﺑﻲ اﻟﺴﻌﻮدي‬
:‫ﻗﻮاﻋﺪ ﻋﺎﻣﺔ‬
‫• ﺷﺮﻛﺔ ﺑﻮﺑﺎ ﺗﻘﻮم ﺑﺘﻐﻄﻴﺔ اﻻﻋﻀﺎء اﻟﺴﻌﻮدﻳﲔ واﳌﻘﻴﻤﲔ اﻟﺬﻳﻦ ﺑﺤﻮزﺗﻬﻢ اﻗﺎﻣﺔ داﺋﻤﺔ وﺳﺎرﻳﺔ‬
‫أو ﻣﻦ ﻳﺤﻤﻠﻮن ﺗﺄﺷ–ات زﻳﺎرة ﲡﺎرﻳﺔ‬/‫ أو ﻳﺤﻤﻠﻮن ﺗﺄﺷ–ة إﻗﺎﻣﺔ ﺳﺎرﻳﺔ اﳌﻔﻌﻮل و‬،‫اﳌﻔﻌﻮل‬
‫ ﻋﻠﻰ ﻗﺒﻮل ﻣﻦ ﻳﺤﻤﻠﻮن ﺗﺄﺷ–ات زﻳﺎرة ﲡﺎرﻳﺔ‬Ë‫ ﺣﺎل ﻗﺎﻣﺖ ﺑﻮﺑﺎ اﻟﻌﺮﺑﻴﺔ ﺑﺎﳌﻮاﻓﻘﺔ ﻣﺴﺒﻘ‬¥ ‫)ﻓﻘﻂ‬
.(‫أو زﻳﺎرة ﻋﻤﻞ‬/‫و‬

• Contract does not include any relatives except husbands/wives ‫اﻟﺰوﺟﺔ واﳌﻌﺎﻟﲔ اﻟﻐ– ﻣﺘﺰوﺟﲔ )ا¯ﺑﻨﺎء اﻟﺬﻛﻮر‬/‫ﻻ ﻳﺸﻤﻞ اﻟﻌﻘﺪ أي أﻗﺎرب ﻣﺎ ﻋﺪا اﻟﺰوج‬ •
and unmarried children (Male children up-to the age of 18 or 25 .(‫م‬٢٠١٤/٠٧/٠١ ‫ ﺳﻨﺔ ﻟﻠﻌﻘﻮد اﻟﺘﻲ ﺗﺒﺪأ ﻣﻦ ﺗﺎرﻳﺦ‬٢٥ ‫ ﺳﻨﺔ أو‬18 ‫ﺣﺘﻰ ﺳﻦ‬
for the contracts starting from 01/07/2014).
• This application form is considered part of the signed contract .‫ﻳﻌﺘ¿ ﻫﺬا اﻟﻄﻠﺐ ﻣﻜﻤ ًﻼ و ﺟﺰء ﻻ ﻳﺘﺠﺰأ ﻣﻦ اﻟﻌﻘﺪ‬ •
and subject to the contract’s terms and conditions.
• Substituting a member by another is not allowed. .‫ة اﻟﻌﻘﺪ‬Ó‫ﻻ ﻳﺤﻖ ﻟﻠﻌﻤﻴﻞ اﺳﺘﺒﺪال ﻋﻀﻮ ﺑﻌﻀﻮ أﺧﺮ ﺧﻼل ﻓ‬ •

2 / ٢
• Customer shall immediately notify the company in writing of all
employees and/or dependents to be covered by insurance
the effective date of the policy, and company shall
immediately calculate additional contribution payable for
persons incorporate in the insured persons schedule on a
proportional basis starting from date of their coverage.
• The coverage of the employee who is actually on the job
shall commence as from date of commencement stated in
the policy - schedule, - and any person who joins work at a
later date shall be covered as from date of joining work with
customer or date of arrival in the Kingdom.
• The effective date of insurance coverage for dependents
shall be the date of insuring the employee – who supports
them – or the first date on which they enjoy the status of
dependents.
• If customer submit request to enroll a member or dependent
under the healthcare program, Bupa Arabia reserves the right to
access the personal files and request any documentation may
find it necessary to decide on the enrolment of any employee or
dependent. This process will be discretionary and can be done
randomly and/or on every case at the point of enrolment or at a
later stage whenever Bupa Arabia identifies a need to do so. If at
any stage Bupa Arabia concludes that there is an intension for
abuse or enrolment circumstances indicates discrepancy in data
provided, Bupa Arabia have the right to fully or partially reject to
cover any service cost and can terminate membership
immediately without any advance notice.
• Backdating transactions should not exceed 30 days period or 10
days onwards.
• If a request was rejected due to missing document/s, please
resubmit all the documents together with the reference number
of the rejection
• Validating member details on CCHI system is based on the (ID
No., Sponsor No., Gender, Year of Birth Nationality and Member
Occupation as per Iqama for non-Saudi and GOSI for Saudis).
Please make sure that these details are correct to avoid any CCHI
rejection.
Terms and Conditions:
A. Conditions of enrollment:
• The member should be an employee within the organization and
holding Saudi ID/Iqama / valid working visa inside the Kingdom.
• Attach a copy of the National ID card for Saudis or Iqama, Entry Visa
Page, GCC citizens’ passport, or diplomatic card for diplomats must
be submitted for non-Saudis when submitting the request.
• As per CCHI regulations, customer should enroll any employee within
10 days of their company joining date.
• Attach a copy of the passport if the applicant has newly arrived
to KSA.
• As per CCHI regulations, all dependents should be covered as per the
CCHI policy.
• Attach a copy of the birth certificate or hospital birth report when
enrolling new born babies. If the newborn age is 3 months or more,
copy of the Iqama/Birth Certificate (For Saudis) must be submitted.
• All newborn babies must be enrolled from their date of birth,
according to CCHI Rules and Regulations. In case of enrolling a
newborn baby with date of birth due to an expired contract, the
newborn will be enrolled from the effective date of the new/renewed
contract.
• In case of late additions for more than 28 days from the contract
inception date, please note that we will only accept the additions of
the following cases:
• Newly married (Saudis or non-Saudis) will be required to provide copy
of the marriage certificate.
• Non-Saudi spouses newly entered to KSA are required to provide
copy of the passport along with copy of the entry stamp page.
• Please note that the addition request will be accepted only if the
request submitted within 3 months from marriage/entry date to KSA.
• Pursuant to the Saudi Ministry of Labor Regulations, the employee
and/or worker must work for their sponsors only, and if the employee
and/or worker is in the process of transferring his/her sponsorship to
you, please note that the employee and/or worker will not be added
until the completion of the sponsor transfer process is completed.
3 /٣
‫أو اﳌُ ﻌﺎﻟﲔ اﳌﺮاد‬/‫ ﻟﻠﺸﺮﻛﺔ ﻋﻦ ﻛﻞ اﳌﻮﻇﻔﲔ و‬Ë‫ وﺧﻄﻴ‬Ò‫ﻋﻠﻰ ﺣﺎﻣﻞ اﻟﻮﺛﻴﻘﺔ أن ُﻳﻌﻠﻦ ﻓﻮر‬ •
‫ اﻟﻮاﺟﺐ‬¥‫اك ا¶ﺿﺎ‬Ó‫ وﺗﻘﻮم اﻟﺸﺮﻛﺔ ﺑﺎﺣﺘﺴﺎب اﻻﺷ‬،‫ﺗﻐﻄﻴﺘﻬﻢ ﺑﺎﻟﺘﺄﻣﲔ ﺑﻌﺪ ﺗﺎرﻳﺦ اﺑﺘﺪاء اﻟﻮﺛﻴﻘﺔ‬
‫اﳌﺆﻣﻦ ﻟﻬﻢ وذﻟﻚ ﻋﻠﻰ أﺳﺎس‬
‫ﱠ‬ ‫ ﺟﺪول ا¯ﺷﺨﺎص‬¥ ‫ ﻋﻦ ا¯ﺷﺨﺎص اﻟﺬﻳﻦ ﻳﺘﻢ إدراﺟﻬﻢ‬Ò‫أداؤه ﻓﻮر‬
.‫ﺗﻨﺎﺳﺒﻲ ﻣﻦ ﺗﺎرﻳﺦ ﺷﻤﻮﻟﻬﻢ ﺑﺎﻟﺘﻐﻄﻴﺔ‬
‫ ﻣﻦ ﺗﺎرﻳﺦ اﻻﺑﺘﺪاء‬Ò‫ ﻋﻠﻰ رأس اﻟﻌﻤﻞ اﻋﺘﺒﺎر‬Ë‫ﻳﺒﺪأ ﻧﻔﺎذ اﻟﺘﻐﻄﻴﺔ ﺑﺎﻟﻨﺴﺒﺔ ﻟﻠﻤﻮﻇﻒ اﳌﻮﺟﻮد ﻓﻌﻠﻴ‬ •
‫ وﻗﺖ ﻻﺣﻖ ﺳﻮف ﺗﺒﺪأ ﺗﻐﻄﻴﺘﻪ ﻣﻦ ﺗﺎرﻳﺦ‬¥ ‫ وﻛﻞ ﺷﺨﺺ ﻳﻠﺘﺤﻖ ﺑﺎﻟﻌﻤﻞ‬،‫ ﺟﺪول اﻟﻮﺛﻴﻘﺔ‬¥ ‫اﶈﺪد‬
.‫اﻟﺘﺤﺎﻗﻪ ﺑﺎﻟﻌﻤﻞ ﻟﺪى ﺣﺎﻣﻞ اﻟﻮﺛﻴﻘﺔ أو وﺻﻮﻟﻪ ﻟﻠﻤﻤﻠﻜﺔ‬
‫ﻳﺒﺪأ ﻧﻔﺎذ اﻟﺘﻐﻄﻴﺔ اﻟﺘﺄﻣﻴﻨﻴﺔ ﺑﺎﻟﻨﺴﺒﺔ ﻟﻠﻤﻌﺎﻟﲔ ﻣﻦ اﻟﺘﺎرﻳﺦ اﻟﺬي أﺻﺒﺢ ﻓﻴﻪ اﳌﻮﻇﻒ واﳌﺴﺌﻮل‬ •
.‫ اﻟﺘﺎرﻳﺦ اﻟﺬي اﻛﺘﺴﺒﻮا ﻓﻴﻪ ¯ول ﻣﺮة ﺻﻔﺔ ُﻣﻌﺎﻟﲔ‬¥ ‫ ﻋﻠﻴﻪ أو‬Ë‫ﻣﺆﻣﻨ‬
‫ﻋﻦ إﻋﺎﻟﺘﻬﻢ ﱠ‬
‫إذا ﻣﺎ ﻗﺎم اﻟﻌﻤﻴﻞ ﺑﺈرﺳﺎل ﻃﻠﺐ إﺿﺎﻓﺔ اﳌﻮﻇﻒ أو ﻓﺮد ﺗﺎﺑﻊ ¯ﺣﺪ اﳌﻮﻇﻔﲔ ﲢﺖ ﺑﺮﻧﺎﻣﺞ اﻟﺮﻋﺎﻳﺔ‬ •
‫ اﳊﺼﻮل ﻋﻠﻰ اﳌﻌﻠﻮﻣﺎت اﻟﺸﺨﺼﻴﺔ وﻃﻠﺐ أي ﻣﺴﺘﻨﺪات‬¥ ‫ ﲢﺘﻔﻆ ﺑﻮﺑﺎ اﻟﻌﺮﺑﻴﺔ ﺑﺤﻘﻬﺎ‬،‫اﻟﺼﺤﻴﺔ‬
‫ أو ﻟﻜﻞ‬Ë‫ ﻫﺬا ا¶ﺟﺮاء ﺳﻴﻜﻮن ﺗﻘﺪﻳﺮي وﳝﻜﻦ ﺗﻄﺒﻴﻘﻪ ﻋﺸﻮاﺋﻴ‬.‫ﲡﺪﻫﺎ ﺿﺮورﻳﺔ ﻟﻘﺒﻮل ﻃﻠﺐ ا¶ﺿﺎﻓﺔ‬
.‫ ﻣﺮاﺣﻞ ﻻﺣﻘﺔ أﻳﻨﻤﺎ ﲡﺪ ﺑﻮﺑﺎ اﻟﻌﺮﺑﻴﺔ وﺟﻮد ﺿﺮورة ﻟﺬﻟﻚ‬¥ ‫أو‬/‫ﺣﺎﻟﺔ ﻋﻨﺪ ﺗﻘﺪﱘ ﻃﻠﺐ ا¶ﺿﺎﻓﺔ و‬
‫ اﻟﺒﻴﺎﻧﺎت اﳌﻘﺪﻣﺔ‬¥ (‫او ﺗﻀﻠﻴﻞ )ﺗﻌﺎرض‬/‫وﻋﻨﺪﻣﺎ ﲡﺪ ﺑﻮﺑﺎ اﻟﻌﺮﺑﻴﺔ وﺟﻮد ﺗﻌﻤﺪ ¶ﺳﺎءة اﻻﺳﺘﺨﺪام و‬
‫ رﻓﺾ ﺗﻐﻄﻴﺔ ﻛﺎﻣﻞ أو ﺑﻌﺾ‬¥ ‫ ﻓﺈن ﺑﻮﺑﺎ اﻟﻌﺮﺑﻴﺔ ﲢﺘﻔﻆ ﺑﺤﻘﻬﺎ‬،‫ﻣﻦ ﻗﺒﻞ اﻟﻌﻤﻴﻞ ﻟﻄﻠﺐ ا¶ﺿﺎﻓﺔ‬
‫¯ﺣﺪ‬/‫أو ا¯ﻓﺮاد اﻟﺘﺎﺑﻌﲔ ﻟﻠﻤﻮﻇﻒ‬/‫ﺗﻜﺎﻟﻴﻒ اﳋﺪﻣﺎت اﻟﻄﺒﻴﺔ اﳌﻄﻠﻮﺑﺔ أو إﻟﻐﺎء ﻋﻀﻮﻳﺔ اﳌﻮﻇﻒ و‬
.‫اﳌﻮﻇﻔﲔ دون إﺧﻄﺎر ﻣﺴﺒﻖ‬
.Ë‫ أﻳﺎم ﻣﻘﺪﻣ‬10 ‫ أو‬Ë‫ ﻳﻮﻣ‬30 ‫ﻳﺴﻤﺢ ﺑﺘﻨﻔﻴﺬ اﻟﻌﻤﻠﻴﺎت ﺑﺄﺛﺮ رﺟﻌﻲ ﻻ ﻳﺰﻳﺪ ﻋﻦ‬ •
‫ اﻟﺮﺟﺎء إﻋﺎدة إرﺳﺎل‬،‫ ﺣﺎل ﰎ رﻓﺾ اﻟﻄﻠﺐ ﺑﺴﺒﺐ ﻋﺪم ﺗﻮاﻓﺮ ﺑﻌﺾ اﳌﺴﺘﻨﺪات اﳌﻄﻠﻮﺑﺔ‬¥ •
.‫اﻟﻌﻤﻠﻴﺔ‬/‫ﺟﻤﻴﻊ اﳌﺴﺘﻨﺪات وذﻛﺮ رﻗﻢ اﳌﺮﺟﻊ‬
،‫ رﻗﻢ اﻟﻜﻔﻴﻞ‬،‫ ﻣﻦ ﺧﻼل )رﻗﻢ اﻟﻬﻮﻳﺔ‬°‫ﻠﺲ اﻟﻀﻤﺎن اﻟﺼﺤﻲ اﻟﺘﻌﺎو‬ä ‫ﺗﺘﻢ آﻟﻴﺔ اﻟﺘﺤﻘﻖ ﻣﻦ ﻗﺒﻞ‬ •
‫اﻟﺘﺄﻣﻴﻨﺎت‬/‫ ا¶ﻗﺎﻣﺔ‬¥ ‫ اﳌﺴﻤﻰ اﻟﻮﻇﻴﻔﻲ ﻛﻤﺎ ﻫﻮ ﻣﺴﺠﻞ‬،‫ اﳉﻨﺴﻴﺔ‬،‫ ﺳﻨﺔ اﳌﻴﻼد‬،‫اﳉﻨﺲ‬
.‫ﻠﺲ‬å‫ا¶ﺟﺘﻤﺎﻋﻴﺔ( ﻟﺬا اﳌﺮﺟﻮ اﻟﺘﺄﻛﺪ ﻣﻦ ﺻﺤﺔ اﻟﺒﻴﺎﻧﺎت ﻟﺘﻔﺎدي اﻟﺮﻓﺾ ﻣﻦ ﻗﺒﻞ ا‬
:‫ﺣﻜﺎم‬À‫اﻟﺸﺮوط وا‬
:‫ﺷﺮوط اﻻﺿﺎﻓﺔ‬ .1
‫إﻗﺎﻣﺔ‬/‫ان ﻳﻜﻮن اﳌﺆﻣﻦ ﻋﻠﻴﻪ ﻣﻮﻇﻔﺎ ﻟﺪى اﻟﺸﺮﻛﺔ أو اﳌﺆﺳﺴﺔ وﻳﺤﻤﻞ ﻫﻮﻳﺔ وﻃﻨﻴﺔ‬ •
.‫ اﳌﻤﻠﻜﺔ‬¥ ‫ ﺗﺄﺷ–ة ﻋﻤﻞ ﺳﺎرﻳﺔ‬/ ‫ﻧﻈﺎﻣﻴﺔ‬
‫ارﻓﺎق ﺻﻮره ﻣﻦ اﻟﻬﻮﻳﺔ اﻟﻮﻃﻨﻴﺔ ﻟﻠﺴﻌﻮدﻳﲔ أو اﻻﻗﺎﻣﺔ أو ﺗﺄﺷ–ة اﻟﺪﺧﻮل أو ﺟﻮاز اﻟﺴﻔﺮ‬ •
،‫ﻠﺲ اﻟﺘﻌﺎون ﻟﺪول اﳋﻠﻴﺞ اﻟﻌﺮﺑﻴﺔ أو اﻟﺒﻄﺎﻗﺔ اﻟﺪﺑﻠﻮﻣﺎﺳﻴﺔ ﻟﻠﺪﺑﻠﻮﻣﺎﺳﻴﲔ‬ä ‫ﳌﻮاﻃﻨﻲ دول‬
.‫ﻟﻠﻤﻮﻇﻔﲔ و اﻻﺑﻨﺎء ﻋﻨﺪ ﺗﻘﺪﱘ اﻟﻄﻠﺐ‬
‫ أﻳﺎم ﻣﻦ ﺗﺎرﻳﺦ اﻻﻟﺘﺤﺎق‬10 ‫ﺲ اﻟﻀﻤﺎن اﻟﺼﺤﻲ ﻳﺠﺐ اﺿﺎﻓﺔ اﳌﻮﻇﻒ ﺧﻼل‬ä ‫وﻓﻘﺎ ﻟﻘﻮاﻧﲔ‬ •
.‫ﺑﺎﻟﻌﻤﻞ‬
.‫ ﺣﺎل ﻛﺎن اﳌﻮﻇﻒ ﻳﺤﻤﻞ ﺗﺄﺷ–ة دﺧﻮل‬¥ ‫ارﻓﺎق ﺻﻮرة ﻣﻦ ﺟﻮاز اﻟﺴﻔﺮ‬ •
‫ ﻳﺠﺐ إﺿﺎﻓﺔ ﺟﻤﻴﻊ اﳌﻌﺎﻟﲔ ﺣﺴﺐ ﻣﺎ‬،°‫ﻠﺲ اﻟﻀﻤﺎن اﻟﺼﺤﻲ اﻟﺘﻌﺎو‬ä ‫ﺣﺴﺐ ﺗﻌﻠﻴﻤﺎت‬ •
.‫ﻠﺲ‬å‫ﺗﻨﺺ ﻋﻠﻴﻪ وﺛﻴﻘﺔ ا‬
‫ ﺣﺎل أن‬¥‫ و‬.‫ارﻓﺎق ﺻﻮرة ﻣﻦ ﺷﻬﺎدة اﳌﻴﻼد أو ﺗﺒﻠﻴﻎ اﻟﻮﻻده ﻋﻨﺪ اﺿﺎﻓﺔ اﳌﻮاﻟﻴﺪ اﳉﺪد‬ •
.(‫ﺷﻬﺎدة اﳌﻴﻼد )ﻟﻠﺴﻌﻮدﻳﲔ‬/‫ أﺷﻬﺮ ﻳﺠﺐ إرﻓﺎق ﺻﻮرة ا¶ﻗﺎﻣﺔ‬3 ‫ ﻣﻦ‬ð‫ﻋﻤﺮ اﻟﻄﻔﻞ اﻛ‬
‫ﻠﺲ اﻟﻀﻤﺎن اﻟﺼﺤﻲ‬ä ‫ ﺣﺴﺐ ﺷﺮوط‬ò‫ﻳﺠﺐ اﺿﺎﻓﺔ اﳌﻮاﻟﻴﺪ اﳉﺪد ﻣﻦ ﺗﺎرﻳﺦ اﳌﻴﻼد‬ •
‫ ﺳﻴﺘﻢ إﺿﺎﻓﺔ اﳌﻮﻟﻮد‬،‫ ﺣﺎﻟﺔ إﺿﺎﻓﺔ ﻣﻮﻟﻮد ﻳﻌﻮد ﺗﺎرﻳﺦ ﻣﻴﻼده إŸ ﻋﻘﺪ ﻣﻨﺘﻬﻲ‬¥‫ و‬.°‫اﻟﺘﻌﺎو‬
.(‫ﺪد‬å‫ﻣﻦ ﺗﺎرﻳﺦ ﺑﺪاﻳﺔ اﻟﻌﻘﺪ اﳉﺪﻳﺪ )ا‬
‫ ﻳﻮم ﻣﻦ ﺗﺎرﻳﺦ ﺑﺪاﻳﺔ اﻟﻌﻘﺪ ﻓﻠﻦ ﻳﺘﻢ ﻗﺒﻮل ﻃﻠﺒﺎت‬28 ‫ ﻣﻦ‬ð‫ ﺣﺎل ﺗﺄﺧﺮ إﺿﺎﻓﺔ اﳌﻌﺎﻟﲔ ¯ﻛ‬¥ •
:‫ اﳊﺎﻻت اﻟﺘﺎﻟﻴﺔ‬¥ ‫ا¶ﺿﺎﻓﺔ إﻻ‬
‫ﺳﻮاء اﻟﺴﻌﻮدﻳﲔ أو ﻏ– اﻟﺴﻌﻮدﻳﲔ )ﻳﻠﺰم ﺗﺰوﻳﺪﻧﺎ ﺑﺼﻮرة ﻣﻦ ﻋﻘﺪ‬
ً ‫اﻟﺰوﺟﺎت اﳉﺪد‬/‫ا¯زوج‬ •
(‫اﻟﻨﻜﺎح‬
‫ ﻟﻠﻤﻤﻠﻜﺔ )ﻳﻠﺰم ﺗﺰوﻳﺪﻧﺎ ﺑﺼﻮرة ﻣﻦ ﺟﻮاز‬Ë‫اﻟﺰوﺟﺎت اﻟﻐ– ﺳﻌﻮدﻳﲔ واﻟﻘﺎدﻣﲔ ﺣﺪﻳﺜ‬/‫ا¯زواج‬ •
(‫اﻟﺴﻔﺮ وﺧﺘﻢ اﻟﺪﺧﻮل‬
‫ أﺷﻬﺮ ﻣﻦ ﺗﺎرﻳﺦ ﻋﻘﺪ اﻟﻨﻜﺎح‬3 ‫ﻧﺮﺟﻮ ﻣﻼﺣﻈﺔ أن اﳌﺪة اﻟﻘﺼﻮى ﻟﻘﺒﻮل ﻃﻠﺒﺎت ا¶ﺿﺎﻓﺔ ﻫﻮ‬ •
.‫أو اﻟﺪﺧﻮل إŸ اﳌﻤﻠﻜﺔ‬/‫و‬
‫ او اﻟﻌﺎﻣﻞ‬/‫ ﻳﺠﺐ ان ﻳﻌﻤﻞ اﳌﻮﻇﻒ و‬،‫ اﳌﻤﻠﻜﺔ اﻟﻌﺮﺑﻴﺔ اﻟﺴﻌﻮدﻳﺔ‬¥ ‫ﺗﻄﺒﻴﻘﺎ ¯ﻧﻈﻤﺔ اﻟﻌﻤﻞ‬ •
،‫ ﺻﺪد اﻧﺘﻘﺎل ﻛﻔﺎﻟﺘﻪ اﻟﻴﻜﻢ‬¥ ‫ ﺣﺎل ﻛﺎن اﳌﻮﻇﻒ او اﻟﻌﺎﻣﻞ‬¥‫ و‬،‫اﳌﻘﻴﻢ ﻟﺪى ﻛﻔﻴﻠﻪ ﻓﻘﻂ‬
.‫ﺟﻮ ﻣﻼﺣﻈﺔ أﻧﻪ ﻟﻦ ﻳﺘﻢ إﺿﺎﻓﺔ اﻟﻌﺎﻣﻞ إﻻ ﺑﻌﺪ إﻛﺘﻤﺎل إﺟﺮاءات ﻧﻘﻞ اﻟﻜﻔﺎﻟﺔ‬ó‫ﻓ‬
• The medical declaration form must be submitted if mentioned in the
signed contract (Note: Each medical declaration form should not
contain more than 1 employee and/or his dependent/s) with
updated Medical Report, additionally for Saudi employees must
submit the GOSI Certificate.
• Valid Iqama numbers must be provided for dependents, which differ
from the main member’s Iqama number (Employee in this case).
B. Conditions of card replacement (Data/Gender correction- lost):
• For date of birth and name amendments, a copy of the member’s
National ID card for Saudis or Iqama, GCC citizens’ passport, or
diplomatic card for diplomats must be submitted for non-Saudis.
• For Saudi ID, Iqama or sponsor ID number amendments, a copy of
the member’s National ID card for Saudis or Iqama, GCC citizens’
passport, or diplomatic card for diplomats must be submitted for
non-Saudis.
• Note: Iqama does not present the sponsorship number so a proof of
sponsorship must be provided.
C. Conditions of re-instating:
• A letter justifying the reason for reinstating the member.
• Medical declaration form signed and stamped by the GS.
Members were terminated for more than 30 days or those
terminated in an expired contract cannot be reinstated, they should
have fresh re-enrollment and the previous membership No. should
be provided.
D. Conditions of deletion:
• Copy of the resignation/termination letter must be submitted for
Saudis.
In case of expatriate members, they will be only deleted according to
the below:
• Final exit (a copy exit visa must be submitted) and stamped by the
exit port or proof of final exit from "Muqeem" website.
• Exit no return (a copy of Attestation of no return must be submitted
“Mashhad Adam Awdah”).
• Transfer of sponsorship “Kafala Transfer” (Submit copy of the new
Iqama along with proof of another valid insurance from an
approved insurance company by the CCHI).
• Death (copy of death certificate or death report must be
submitted).
• Deletion process will only take place, upon the date of receiving of
the insurance cards/ membership cards of the terminated
employees.
• Reference to the decision of the Council of Cooperative Health
Insurance session No. 72 dated on 4-3-1430H – 1-3-2009 on how to
handle workers whom ran away from their sponsors; it has been
decided that health insurance company are not allowed to
terminated the policies of these workers and they should remain
active till it expires.
E. Conditions of upgrade or downgrade:
• When requesting a scheme upgrade, a copy of the promotion letter
must be attached (signed and stamped).
• When requesting a scheme downgrade, a copy of a letter justifying
the downgrade must be attached. (Signed and stamped).
4 / ٤
‫ ﻛﻞ ﳕﻮذج اﻓﺼﺎح ﻃﺒﻲ‬:‫ﻳﺠﺐ ارﻓﺎق ﳕﻮذج اﻻﻓﺼﺎح ﻟﻠﻌﻘﻮد اﻟﺘﻲ ﺗﻨﺺ ﻋﻠﻰ ذﻟﻚ ) ﻣﻼﺣﻈﺔ‬ •
،‫ ﺣﺎل وﺟﻮد ﺣﺎﻟﺔ ﻃﺒﻴﺔ ﻳﺠﺐ إرﻓﺎق ﺗﻘﺮﻳﺮ ﻃﺒﻲ ﺣﺪﻳﺚ‬¥‫ﻳﺨﺺ ﻣﻮﻇﻒ واﺣﺪ ﻣﻊ أﺳﺮﺗﻪ( و‬
.(‫ﺑﺎ¶ﺿﺎﻓﺔ اŸ ﺻﻮرة ﺷﻬﺎدة ﺗﺴﺠﻴﻞ اﻟﺘﺄﻣﻴﻨﺎت ا¶ﺟﺘﻤﺎﻋﻴﺔ )ﻟﻠﻤﻮﻇﻔﲔ اﻟﺴﻌﻮدﻳﲔ ﻓﻘﻂ‬
(‫ﻳﺠﺐ ﺗﺰوﻳﺪ أرﻗﺎم ا¶ﻗﺎﻣﺎت اﳋﺎﺻﺔ ﺑﺎﳌﻌﺎﻟﲔ واﻟﺘﻲ ﺗﺨﺘﻠﻒ ﻋﻦ اﳌﻮﻇﻒ )اﳌﻌﻴﻞ‬ •
:(‫اﳉﻨﺲ‬/‫ ﺗﺼﺤﻴﺢ اﳌﻌﻠﻮﻣﺎت‬-‫ﺷﺮوط اﺳﺘﺒﺪال اﻟﺒﻄﺎﻗﺔ )ﺑﺪل ﻓﺎﻗﺪ‬ .2
‫ ﻳﺠﺐ إرﻓﺎق ﺻﻮره ﻣﻦ اﻟﻬﻮﻳﺔ اﻟﻮﻃﻨﻴﻪ‬،‫ ﺗﺎرﻳﺦ اﳌﻴﻼد أو اﳉﻨﺲ‬،‫ﻋﻨﺪ ﻃﻠﺐ ﺗﻌﺪﻳﻞ اﻻﺳﻢ‬ •
‫ﻠﺲ اﻟﺘﻌﺎون ﻟﺪول اﳋﻠﻴﺞ اﻟﻌﺮﺑﻴﺔ أو‬ä ‫ﻟﻠﺴﻌﻮدﻳﲔ أو ا¶ﻗﺎﻣﺔ أو ﺟﻮاز اﻟﺴﻔﺮ ﳌﻮاﻃﻨﻲ دول‬
.‫اﻟﺒﻄﺎﻗﺔ اﻟﺪﺑﻠﻮﻣﺎﺳﻴﺔ ﻟﻠﺪﺑﻠﻮﻣﺎﺳﻴﲔ‬
‫ ﻳﺠﺐ ارﻓﺎق ﺻﻮه ﻣﻦ اﻟﻬﻮﻳﺔ‬،‫ﻋﻨﺪ ﻃﻠﺐ ﺗﻌﺪﻳﻞ رﻗﻢ اﻟﻬﻮﻳﺔ اﻟﻮﻃﻨﻴﺔ أو ا¶ﻗﺎﻣﺔ أو رﻗﻢ اﻟﻜﻔﻴﻞ‬ •
‫ﻠﺲ اﻟﺘﻌﺎون اﳋﻠﻴﺠﻲ أو اﻟﺒﻄﺎﻗﺔ‬ä ‫ ﺟﻮاز اﻟﺴﻔﺮ ﳌﻮاﻃﻨﻲ دول‬،‫ا¶ﻗﺎﻣﺔ‬، ‫اﻟﻮﻃﻨﻴﺔ ﻟﻠﺴﻌﻮدﻳﲔ‬
.‫اﻟﺪﺑﻠﻮﻣﺎﺳﻴﺔ ﻟﻠﺪﺑﻠﻮﻣﺎﺳﻴﲔ‬
.‫ ا¶ﻗﺎﻣﺔ ﻻ ﺗﻮﺿﺢ رﻗﻢ اﻟﻜﻔﻴﻞ ﻟﺬا ﻳﺠﺐ إرﻓﺎق ﻣﺎ ﻳﺜﺒﺖ رﻗﻢ اﻟﻜﻔﻴﻞ‬:‫ﻣﻼﺣﻈﺔ‬ •
:‫ ﺷﺮوط اﻋﺎدة ﺗﻔﻌﻴﻞ ﻋﻀﻮﻳﺔ ﻣﻠﻐﺎه‬.3
.‫ﺧﻄﺎب ﻳﺒﲔ ﺳﺒﺐ اﻋﺎدة اﻟﺘﻔﻌﻴﻞ‬ •
.‫ اﻟﺸﺮﻛﺔ‬¥ ‫ﻮل‬ö‫ﳕﻮذج ا¶ﻓﺼﺎح اﻟﻄﺒﻲ ﻣﻮﻗﻊ و÷ﺘﻮم ﻣﻦ اﻟﺸﺨﺺ ا‬ •
‫ ﻫﺬه‬¥‫ ﻋﻘﺪ ﻣﻨﺘﻬﻲ و‬¥ ‫ ﻳﻮم أو ﰎ اﻟﻐﺎﺋﻬﺎ‬30 ‫ ﻣﻦ‬ð‫ﻻ ﳝﻜﻦ إﻋﺎدة ﺗﻔﻌﻴﻞ ﻋﻀﻮﻳﺔ ﻣﻠﻐﻴﺔ ¯ﻛ‬ •
.‫اﳊﺎﻟﺔ ﻳﺠﺐ إﻋﺎدة إﺿﺎﻓﺔ اﻟﻌﻀﻮ ﻣﻊ ﺗﺴﺠﻴﻞ رﻗﻢ اﻟﻌﻀﻮﻳﺔ اﻟﺴﺎﺑﻘﺔ‬
: ‫ﺷﺮوط اﻻﻟﻐﺎء‬ .4
.‫اﻟﻔﺼﻞ إذا ﻛﺎن اﳌﺆﻣﻦ ﻋﻠﻴﻪ ﻳﺤﻤﻞ اﳉﻨﺴﻴﺔ اﻟﺴﻌﻮدﻳﺔ‬/‫ﺻﻮرة ﻣﻦ ﺧﻄﺎب اﻻﺳﺘﻘﺎﻟﺔ‬ •
:‫ اﳊﺎﻻت اﻟﺘﺎﻟﻴﺔ‬Ã ‫ ﻓﺴﻴﺘﻢ اﻟﻐﺎء‬،‫ اﻟﺴﻌﻮدﻳﲔ‬Æ‫ ﺣﺎل ﻛﺎن اﳌﺆﻣﻦ ﻋﻠﻴﻪ ﻣﻦ ﻏ‬Ã‫و‬
‫ ) إرﻓﺎق ﺻﻮرة ﻣﻦ ﺗﺄﺷ–ة اﳋﺮوج اﻟﻨﻬﺎﺋﻲ( ÷ﺘﻮﻣﺔ ﺑﺨﺘﻢ اﳌﻨﻔﺬ أو إﺛﺒﺎت‬،‫اﳋﺮوج اﻟﻨﻬﺎﺋﻲ‬ •
."‫اﳋﺮوج اﻟﻨﻬﺎﺋﻲ اﻟﺼﺎدر ﻣﻦ ﻣﻮﻗﻊ "ﻣﻘﻴﻢ‬
.(‫ )ارﻓﺎق ﺻﻮره ﻣﻦ ﻣﺸﻬﺪ ﻋﺪم اﻟﻌﻮدة اﻟﺼﺎدر ﻣﻦ اﳉﻮازات‬،‫اذا ﺗﺨﻠﻒ اﳌﻘﻴﻢ ﻋﻦ اﻟﻌﻮدة‬ •
‫ )ارﻓﺎق ﺻﻮر ﻣﻦ ا¶ﻗﺎﻣﺔ اﳉﺪﻳﺪة ﻣﻊ ﺗﻘﺪﱘ ﻣﺎ ﻳﺜﺒﺖ وﺟﻮد ﺗﺄﻣﲔ آﺧﺮ ﺳﺎري‬،‫ﻧﻘﻞ اﻟﻜﻔﺎﻟﺔ‬ •
.(°‫ﻠﺲ اﻟﻀﻤﺎن اﻟﺼﺤﻲ اﻟﺘﻌﺎو‬ä ‫اﳌﻔﻌﻮل ﻣﻦ ﺷﺮﻛﺔ ﻣﺆﻫﻠﺔ ﻣﻦ‬
.(‫ ) ارﻓﺎق ﺻﻮرة ﻣﻦ ﺷﻬﺎدة اﻟﻮﻓﺎة‬،‫ ﺣﺎﻟﺔ اﻟﻮﻓﺎة‬¥ •
‫ﺷﺨﺎص اﳌﺆﻣﻦ ﻋﻠﻴﻬﻢ ﻓﻘﻂ اﻋﺘﺒﺎرا ﻣﻦ ﺗﺎرﻳﺦ اﺳﺘﻼم‬ø‫ﺳﻮف ﻳﺘﻢ ﺗﻨﻔﻴﺬ ﻋﻤﻠﻴﺔ اﻻﻟﻐﺎء ﻟ‬ •
.‫اﻟﺸﺮﻛﺔ ﻟﺒﻄﺎﻗﺎت اﻟﺘﺄﻣﲔ‬
‫ ه ﺑﺸﺄن ﻛﻴﻔﻴﺔ‬1430/3/4 ‫ واﳌﻨﻌﻘﺪة ﺑﺘﺎرﻳﺦ‬72 ‫ ﺟﻠﺴﺘﻪ رﻗﻢ‬¥ ‫ﻠﺲ‬å‫اﳝﺎء اŸ ﻗﺮارات ا‬ •
‫ ﻓﻘﺪ ﺗﻘﺮر اﻧﻪ ﻻ ﻳﺤﻖ ﻟﺸﺮﻛﺔ اﻟﺘﺎﻣﲔ اﻟﻐﺎء وﺛﻴﻘﺔ‬.( ‫اﻟﺘﻌﺎﻣﻞ ﻣﻊ اﻟﻌﺎﻣﻞ اﳌﺘﻐﻴﺐ ) اﻟﻬﺎرب‬
.‫ ﺣﺎل ﻫﺮوﺑﻪ ﳊﲔ اﻧﺘﻬﺎء ﻣﺪة اﻟﻮﺛﻴﻘﺔ اﳉﺎرﻳﺔ‬¥ (‫اﻟﺘﺎﻣﲔ اﻟﺼﺤﻲ ﻟﻠﻌﺎﻣﻞ اﳌﺘﻐﻴﺐ )اﻟﻬﺎرب‬
‫ﺷﺮوط ﺗﻌﺪﻳﻞ اﻟﺪرﺟﺔ أو اﻟﻔﺌﺔ‬ .5
‫ﻗﻴﺔ‬Ó‫ ﻳﺠﺐ ارﻓﺎق ﺻﻮرة ﻣﻦ ﺧﻄﺎب اﻟ‬،‫ﻋﻨﺪ ﻃﻠﺐ ﺗﺮﻗﻴﺔ اﻟﺘﻐﻄﻴﺔ اﻟﺘﺄﻣﻴﻨﻴﺔ ﻟﺪرﺟﺔ أﻋﻠﻰ‬ •
.(‫)ﻣﻮﻗﻌﺎ و ÷ﺘﻮﻣﺎ ﻣﻦ اﻟﺸﺨﺺ اﳌﺴﺆول ﻟﺪى اﻟﺸﺮﻛﺔ‬
‫ ﻳﺠﺐ ارﻓﺎق ﺧﻄﺎب ﻳﻮﺿﺢ ﺳﺒﺐ اﻟﺘﻌﺪﻳﻞ‬،‫ﻋﻨﺪ ﻃﻠﺐ ﺗﻐﻴ– درﺟﺔ اﻟﺘﻐﻄﻴﺔ اŸ درﺟﺔ أﻗﻞ‬ •
.(‫)ﻣﻮﻗﻌﺎ و ÷ﺘﻮﻣﺎ ﻣﻦ اﻟﺸﺨﺺ اﳌﺴﺆول ﻟﺪى اﻟﺸﺮﻛﺔ‬