MedNetGulf


Home	Network Providers	Insured Members	Become a Member	Insurance Companies	About Us	Career	Contact

Corporate Benefit Medical Insurance Application

Policy Holder Name:		Nature of Business:
Person in Charge:		E-mail Address:
Telephone:		Fax:
P.O. Box:		Date Cover Required:

A. Are You currently insured for medical insurance or self funded? Insured Self Funded
B. If Insured, please Provide details:
Name of Insurer	Year	Claims Paid	Claims Outstanding

C. Has your company ever been insured under the MedNet Network before? Yes No
If Yes, Please provide details:

D. Please discribe your internal HR policy in respect of providing Medical Insurance:

E. Will/Is any part of the premium paid by the employee? Yes No

F. Do you currently have any (In-House) clinic visiting your premises on a daily / weekly basis? Yes No
If Yes, Please provide details:

G. No.of Members: Employees: Spouse: Children: Total Members No.

H. Are All insured members permanently residing in KSA? Yes No
If No, Please provide full details with location wise list:

I. Where are your employees within KSA located?
Central Prov. % Western Prov. % Eastern Prov. % Other %

E. Are you a aware of any insured member(s) having any chronic / pre-existing condition(s), suffering from illness, injury or undergoing treatment by a doctor or on medical leave? Yes No

Back