Client's Information
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    Full Name*

    Marital Status*

    Date Of Birth*

    Gender*
    Nationality*

    ID No.*

    National No.*

    ID Type*

    Phone Number*

    Email Address*

    Address: Country, City, Area, Building No... Street Name*

    Work Address

    Occupation*

    Insurance information

    Insurance Amount?
    Beneficiaries*

    Relation*

    Insurance Starting Date*

    Note: INSURANCE ENDING DATE AFTER 1 YEAR BY DEFAULT

    Do you drink alcoholic beverages?
    Height*

    Weight*

    Did your weight dramatically changed during last year?
    Do you Smoke?
    Have you ever applied for life, accident or health insurance and it was rejected or accepted with special terms and prices? Or was it canceled or refused to renew or re-enforce, or was it renewed with a higher premium?
    Have you ever done cancer tests and results were abnormal or are you currently advised or waiting for cancer test results (including lab results, CT, biopsy)?
    Have you ever been diagnosed or received treatment for HIV/AIDS, hepatitis B or C, or are you waiting for results of such tests?
    Have you been advised to receive treatment for any of the following: Cancer or any malignancy, colon polyp, or other growth? Gastrointestinal disorders such as ulcerative colitis or cirrhosis?
    Do you have health problems,or did you undergo medical examination & the results were abnormal?
    How many first-degree relatives (e.g. mother, sister, daughter) has any type of cancer (including non-metastatic cancer) under the age of 60?
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    Do you currently suffer from any type of cancer?
    Do you have first-degree relatives who suffer from any type of cancer?
    Where did you hear about our Amal program?*

    Name of Employee