Membership Maintenance Form.pdf

7/29/2019 Membership Maintenance Form.pdf

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Membership Maintenance Form

All the below fields are mandatory, please fill in clear font

..

Transaction effective date

Please fax this page to

920 000 725

Contract Number

Company Name

TRANSACTION TYPE /

Please choose (fill in) one of the below transactions:

All the below options require additional documentation (refer to general rules inpage 3). For any assistance on how to fill out the form, please read the guidelines inthe following pages.

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Add new employee and dependent(s)

Add new born

Add dependent(s) of an insured employee

Replace card(s)(lost/ Data correction) Employee Dependents )-(

Re-activating

Delete an employee ( Dependents will be deleted automatically) )(

Delete a dependent(s) only

Employee Upgrade or Downgrade (and dependents)

Transfer to new Branch EMPLOYMENT DETAILS /

Current membership no (skip if new member)

)(Gender

F

M

Employee No.

Name as p er the ID ( First Middle Last )

( ) --

Date of Birth (Gregorian)

)(

DD/MM/YYYY Requested Level of Cover

Iqamaor Saudi ID

Sponsor ID

Nationality

Branch name

Reason

DEPENDENTS DETAILS /Current

membership no (skip ifnew member)

)

(

Name as per the ID( First Middle Last )

( -- )

Iqama or Saudi ID

Date of Birth

DD / MM / YYYY

Nationality

Relationship

Gende

Please mark this box if you have more than 4 dependents to add andfollow step 3 in the guidelines (page2)

4 32

I certify that the information given on this form and in any documents attached iscorrect, complete and accurate. I understand that the information provided by memaybe verified and hereby consent to such verification activities. I also understandthat providing false or misleading information may result in canceling the membershipand may be grounds for any legal accountability.

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Company Stamp / : Authorized name and s ignature / :


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Guidelines:

This section provides some guidelines on how to fill in page

1. Depends on transaction type, you get to fill in the

necessary information that satisfy our requirements. You can

always call our membership team on 800 4400 555 for any

clarifications during the working hours (9 am- 5 pm) Sat to Wed. :

1. Transaction date, contract number and company name are

mandatory fields and must always be provided, regardless of

the transaction type.

2.Pease refer to the below schedule and make sure you fill all

the fields corresponding to their numbers stated below:

Transaction typ eMandatory field

numberNotes

Add new Employeeand Dependents

Employee only:

From 2 to 10

Employee anddependent:

From 2 to 10And

From 13 to 18

3 only if applicable

Add new born1 - 4 - 7 - 8

From 13 to 18

Add dependents ofan insured employee

1 - 4 - 7 - 8

From 13 to 18

Replace cards 1 - 4 - 11

The fields from (2 to 10for employees or from12 to 16 for

dependents) will befilled according to thereason.

Example: if the reasonis wrong Employee

name, field number 2must be filled

Re-activating

For Employee:

1 - 4 - 11For Dependents:

1 - 4 - 11 - 12 - 13

Delete an employeeand Dependents

1 - 4 - 11

Delete Dependents 11 - 12 - 13 - 14

Employee upgradeor downgrade

1 - 4 - 6 - 11

Transfer to a new

branch1 - 4 - 10

In field no. 10, only the

new branch namemust be provided.

3. If you wish to add more than 4 dependents, please fill-in the

second form dependents addition and make sure you do the

following:

Fill-in all the fields because all are mandatory.

Sign it and stamp it.

Fax this request together with the original one.

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.

800 4400 555)9-5(.:

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1-4-7-8

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The below rules were designed in compliance with the

Council of Cooperative health Insurance (CCHI) and Saudi

Arabian Monetary Agency (SAMA):

General rules:

Bupa covers Saudi nationals and members who are having

valid Iqama or valid resident visa.

Agreement does not include any relatives except wives and

unmarried children.

This application form is considered part of the signed

agreement and subject to the agreements terms and

conditions.

Substituting a member by another is not possible.

Customer shall immediately notify the company in writing of all

employees or dependents to be covered by insurance after the

effective date of the policy, and company shall immediately

calculate additional contribution payable for personsincorporate in the insured persons schedule on a proportional

basis starting from date of their coverage.

The coverage of the employee who is actually on the job shall

commence as from date of commencement stated in the policy

- schedule, - and any person who joins work at a later date

shall be covered as from date of joining work with customer or

date of arrival in the Kingdom.

The effective date of insurance coverage for dependents shall

be the date of insuring the employee - who supports them - or

the first date on which they enjoy the status of dependents.

If customer submit request to enroll a member or dependent

under the healthcare program, Bupa Arabia reserves the right

to access the personal files and request any documentationmay find it necessary to decide on the enrolment of any

employee or dependent. This process will be discretionary and

can be done randomly or on every case at the point of

enrolment or at a later stage whenever Bupa Arabia identifies a

need to do so. If at any stage Bupa Arabia concludes that there

is an intension for abuse or enrolment circumstances indicates

discrepancy in data provided, Bupa Arabia have the right to

fully or partially reject to cover any service cost and can

terminate membership immediately without any advance

notice.

Backdating enrollment and deletions must not exceed 30 days

period.

Terms and Conditions:

A. Condit ions of enrollment:

The member should be an employee within the organization.

Attach a copy of the National ID card for Saudis or Iqama, GCC

citizens passport, or diplomatic card for diplomats must be

submitted for non Saudis when submitting the request

Per CCHI regulations, customer should enroll any employee

within 10 days of their company joining date.

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Attach a copy of the passport if the applicant has newly arrived

to KSA.

Attach a copy of the birth certificate or hospital birth report when

enrolling new born babies.

All new born must be added from their date of birth, according

to the signed agreement.

Attach a copy of mirage certificate when enrolling spouses. Adding an employee on a different sponsor will require

attaching the following documentation:

Copy of Employees contract

Copy of the employment lease (labor lease contract)

signed and stamped by the Chamber of Commerce.

Copy of the letter of the responsibility pledge, signed and

stamped (please check with the Relationship manager

for details)

Attach a copy of the medical deceleration form, once it is

clearly stated in the signed agreement.

Valid Iqama numbers must be provided for dependents, which

differ from the main members Iqama number (Employee in this

case).

B. Conditions of card replacement (data correction- lost):

For date of birth and name amendments, a copy of the

members National ID card for Saudis or Iqama, GCC citizens

passport, or diplomatic card for diplomats must be submitted for

non Saudis.

For Saudi ID, Iqama or sponsor ID number amendments, a

copy of the members National ID card for Saudis or Iqama,

GCC citizens passport, or diplomatic card for diplomats must

be submitted for non Saudis.

C. Conditions of re-instating:

A letter justifying the reason for reinstating the member. A confirmation that the member doesnt suffer from any major

health condition.

D. Conditions of deletion:

Copy of the resignation letter must be submitted for Saudis.

In case of expatriate members, they will be only deleted

according to the below:

Final exit (a copy exit visa must be submitted).

No return (a copy of Attestation of no return must be submitted

Mashhad Adam Awdah).

Sponsorship transfers Kafala Transfer (the client needs to

submit the sponsorship transfer documents along with aconfirmation letter of membership from a CCHI approved

company) before terminating the member.

Death (copy of death certificate or death report must be

submitted).

Deletion process will only take place, upon the date of receiving

of the insurance cards/ membership cards of the terminated

employees.

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Reference to the decision of the Council of Cooperative Health

Insurance session No. 72 dated on 4-3-1430H 1-3-2009 on

how to handle workers whom ran away from their sponsors; it

has been decided that health insurance company are not

allowed to terminated the policies of these workers and they

should remain active till it expires.

E. Conditions of upgrade or downgrade: When requesting a scheme upgrade, a copy of the promotion

letter must be attached ( signed and stamped )

When requesting a scheme downgrade, a copy of a letter

justifying the downgrade must be attached. ( signed and

stamped )

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Documents

Membership Maintenance Form.pdf