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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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Please complete all mandatory fields marked with RED

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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Name of entity The value of the installment Installment Period (Month) Original borrowed amount The remaining borrowed amount

Do you have a down payment?

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Is this the first home

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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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Declaration and undertaking

for the questionnaire form of medical insurance on life or disability

On…./…/…. هـ - …/…/…I acknowledge
Saudi, ID 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. Have you ever consulted a doctor for any disease during the past three years, are you currently undergoing any medical treatment, do you intend to seek medical advice or treatment, or have you taken any medical test?
2. Have you been smoking cigarettes or any other form of tobacco in the past 12 months? If yes, how many times a day?
3. Have you ever been refused, postponed or modified your life insurance, or are you aware of any impairment in your health or physical condition?
4. 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?
5. A question concerning HIV / AIDS, please provide details of any question answered yes:
Have you ever received treatment or counseling related to AIDS or any other physically transmitted disease?
Have you ever been told that you have AIDS or AIDS symptoms? Have you ever reported or been diagnosed with a blood test with HIV antibodies, or do you have any of the following conditions that have not been explained: fatigue, weight loss, diarrhea, enlarged lymph nodes or any unusual skin lesions?

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.

Status details
Status details
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