• 8001221228



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Please complete all mandatory fields marked with RED

I acknowledge that all of the above information are true and under my responsibility. I also undertake to notify the Saudi Home Loans Company of any change to the above information, with my liability arising from my negligence in doing so. I hereby declare, with my agreement, to provide (Saudi Home Loans Company) with any information requested by me to open and / or, audit, and / or manage my accounts and facilities and authorize me to collect all necessary information from Saudi Credit Bureau (SIMAH). I also authorize it to disclose and share all information to and from a feature (under the Information Sharing Agreement) or to any party approved by SAMA. I also acknowledged that in case of retrogression or reversal of the completion of the transaction before the completion of the closing of the real estate deed in favoer of the Saudi Home Loans, I waive the amount of the valuation and / or administrative fees. ( ) SR. The assessment fee is non-refundable upon request for property evaluation

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I/We declare that the documents submitted for identification are original and all particulars given are true and correct. I/We further declare that I/we do not have any other names or identification particulars, apart from the ones submitted above. The information supplied by me/us, as regards to identification particulars are true and correct and any wrong information given can render Financing Contract void

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We will inform you about the property mentioned above with information regarding the owner of the property and the value of the property as follows

The above property is offered to us.We acknowledge that we are the sole beneficiaries in the above quest and have no partners in it

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for the questionnaire form of medical insurance on life or disability

On
Corresponding
I acknowledge /
Saudi with NID number

signed below provides that the answers provided by me in the questionnaire form required for cooperative medical insurance for life or disability are correct according to my knowledge and belief. I have completed the answer to the questionnaire form required by myself after reading and understanding all the questions. On behalf of myself and any person who may have an interest in any insurance contract issued on the basis of the medical questionnaire signed by me, we acknowledge that Non-disclosure any medical fact on the medical questionnaire form will result in the rejection of any claim. In fulfilling the promise of ownership in my name or in the name of my heirs.

General questions

1. During the past five years, has it occurred if you were unable to work for 30 consecutive days?
2. Have you ever been diagnosed with heart disease, high blood pressure, diabetes, urine sugar, kidney disease, lung disease, cancer, back or joint disorder, neurological disorder or abdominal disorder? For treatment or intend to seek medical advice or treatment or a medical test for any of the above?
3. Have you ever had a serious injuries ?
4. Have you ever had a surgical operation or advised to do a surgical operation ?
5. Have you ever took or still taking a treatment or medication for any disease or disorder
6. Are you seeking for a medical advice, treatment, or have you performed any medical examination before ?
7. Have you ever had an examination for HIV / AIDS or hepatitisand and showed postive results , or have you been examined or treated for any of the sexually transmitted diseases, or if you are awaiting the results of these tests? Please provide details if yes
8. Have you ever smoked in the past 12 months? Please list the number of cigarettes per day if yes
9. Did it happen if one of your parents, brothers, or sisters died or suffered from heart or circulatory diseases, cancer, diabetes, kidney disease, and genetic disorders before the age of 65? Please specify the age of condition timing if yes

If you answered “Yes” to any of the above paragraphs, please provide the full details below (if the reason for the consultation is to perform the test, please specify the reason for the examination with the type of test and the date of the test and any available results) Please use an external paper as needed and attach hospital discharge report and recent medical reports from your Doctor.

Question number Status details Duration of the continuation the status History of treatment The date of recovery completely Month /Year Name and address of doctor
Has any close family member ever died or suffered from any of the above cases?
Family Member Age Health condition /Reason of death Age when diagnosed Age at death
Obligation

I am the undersigned and I intend to have my life insurance, and state that the statements written above in this application, whether in writing or not, are correct and complete to the best of my knowledge and belief and any wrong information of this statement will cancel this document. I acknowledge that I will not be required to pay me any benefits as a result of this contract for claiming heart problems, stroke, cancer, diabetes, HIV infection or any other condition that I had been aware of, or which I had been aware of, I hereby agree and authorize Medgulf to obtain any information from any physician at any time with respect to any physical or mental health or to obtain any information from any insurance company. A life insurance application has been filed and has the right to take such information. I also authorize the company to review the health facilities for any information it deems necessary to obtain.

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8001221228