Policy Schedule

Insured / Insurance Company Name: ___________________________

Code:

Policy No.: ____________________                  Policy Holder Code:___________

_________________________________________________________________

Policy Holder Name:

Postal Address:

Tel. No. ____________ Fax No. ________________ C.R. No._____________

Type of insurance: Obligatory Cooperative Health Insurance

Policy term / insurance term: From ______ day ______ month ______

year to ________ day ____________ month _______________ year

(inclusive)

Renewal date of Policy: ____________ day ___________ month ____________

(Year)

Annual Contribution : SR_________________

Persons Eligible for Insurance:

All employees on the job and whose ages are less than 65 years shall be eligible for insurance as of the effective date of policy. Employees joining policy holder later

on – who are less than 65 years old – shall be eligible for insurance as from date of their joining service or date of arrival in the Kingdom.

Husband / Wife – Maximum age: Below 65 year at the effective date of insurance coverage.

Children:              Minimum age:                         Date of Birth:

Sons:                    Maximum age: 18 years         

The insurance coverage of this policy shall include the employee’s unmarried, widowed & divorced daughters who are not working and are supported by the

employee, upto the maximum age specified for the employee himself.

Benefits & Limit of Coverage under the policy

- Maximum benefit limit for each person per year.  SR. 250 000

Out patient Clinic Treatment Charges:

Deduction / Portability: (the percentage paid by the beneficiary when calling on a physician including, consultations, examinations and medicine required by the physician – in one indivisible lot 20% - SR 100 maximum.

Maximum check up fees !                                                        SR. 50

General practitioner

Specialist / Consultant

(patient referred from General Practitioner)

Specialist / Consultant                                                            SR. 50

(patient referred from General Practitioner)

In patient charges:

- Deduction / portability                                                          None

- Daily room & board limit                         Two bed room SR. 350 per day

                                                                   maximum

Pregnancy & Delivery                                Maximum SR 10000

(If the beneficiary (employee) is on a                   during the term of policy

Married status.

Prematurely born child                               Maximum benefit limit

Repatriation of the remains to country                SR. 10 000 maximum

of origin

Coverage Area                                           Kingdom of Saudi Arabia

Calculation of Contributions:

Type of registration:                                   Contribution per person per

                                                                   Each insurance year

Employee                                                   SR______________

Husband / wife                                           SR______________

Children                                                      SR _____________

Policy holder has read and agreed on the provisions and conditions of this policy and schedule thereof.

Date                                         Policy holder                  Insurance    company

                                                Signature                       Signature