Phone: +96176440340
Email: his@hosriholding.com
Home
About Us
Our Services
Contact
Get a Quote
Get a Quote
Medical Insurance Quote
Home
Medical Insurance Quote
Our Services
Cash Insurance
Expat Insurance
Life Insurance
Marine Insurance
Medical Insurance
Motor Insurance
Pet Insurance
Property Policy
Travel Insurance
Workmen Insurance
Yacht Insurance
Contact Info
Email Address
his@hosriholding.com
Phone Number
(+961) 76 440 340
Location
Lebanon: Beirut, 162 Badaro Street 2058162
How Can We Help?
(+961) 76 440 340
his@hosriholding.com
Individual Insurance Policy
Policy Holder
Name
Father
Family
Address
Mohafaza
Caza
City
Street Name
Phone Number
Email Address
Marital Status
Nationality
Profession
Insured Details
Field Group
Were all your family members previously insured?
Yes
No
Which Company?
Do you or any of your family members travel abroad?
Yes
No
Frequency?
What is your family doctor's name?
Family Members Names
Male / Female
Date of Birth
Height
Weight
Relation with Policy Holder
Health Plan
Class
Lux
A
B
ECO
NSSF
With NSSF
W/O NSSF
Optional Coverage
Ambulatory (Out)
Prescription Medicine
Doctor Visit
Medical Questionnaire
1. Hypertension or any cardiac or circulatory system disease?
Yes
No
2. Asthma, bronchitis, tuberculosis or any lungs disease?
Yes
No
3. Cancer, tumors, anemia or any other blood or skin disease?
Yes
No
4. Kidneys, calculus, stones, bladder, urinary tract or prostate?
Yes
No
5. Ear or throat disease, nose deviation or disease?
Yes
No
6. Cataract, or any eye disease?
Yes
No
7. Epilepsy, nervous breakdown, brain or nervous disorder?
Yes
No
8. Stomach, liver, hernia, hemorrhoids or any digestive system disease?
Yes
No
9. Sciatica, lumbago diseases, stiffness of the back, hernias, disk dislocation, retro-spinal pain?
Yes
No
10. Did any of you or your family gain or lose weight during the past 12 months?
Yes
No
11. AIDS or any human immuno-deficiency disease?
Yes
No
12. Any congenital malformation or disablement?
Yes
No
13. Fractures, Arthrosis, Rheumatism or any other bone or ligament diseases?
Yes
No
14. Any disease in reproductive system, infertility or STD?
Yes
No
15. Thyroid, diabetes or any other lymphatic disease?
Yes
No
16.Any drug or alcohol abuse?
Yes
No
17. Any bodily injury due to an accident?
Yes
No
18. Do you suffer from any other disease or are you under any type of medication?
Yes
No
19. Did any of your close family members suffer from any disease?
Yes
No
20. Females only: irregular or heavy periods, breast or any other female disease?
Yes
No
21. Females only: Are you pregnant?
Yes
No
22. Does any of the applications practice any kind of sport (Motorcycle or dangerous sport)?
Yes
No
23. Do you or any of your family members carry a hereditary disease or suffer from a chronic illness that requires constant follow-up or treatment, or that has caused the death of any of your family members?
Yes
No
If you answered "Yes" for any of the above questions, please add the details below:
Person's Name
Question No
Diagnosis
Details of treatment, doctor name etc…
Send Message
Group Insurance Policy
Company Details
Company Name
Address
Mohafaza
Caza
City
Street Name
Phone Number
Email Address
Type of Business
Number of employees
Insured Details
Field Group
Was there a previous medical insurance
Yes
No
Which Company?
Expiry Date of previous insurance
Number of Insured
(Census List to be provided) Number of Insured > 55
Is the insurance mandatory to all employees?
Yes
No
Mandatory to their relatives (Spouse, Daughter, Son & Parents)?
Yes
No
Is there any pregnancy at the moment?
Yes
No
Number of persons
Does anybody suffer from any chronic disease?
Yes
No
Number of persons
Coverage Details
Requested Coverage
IN Hospital
OUT
Drugs
Doctor Visit
Class
A
B
C
NSSF
With NSSF
W/O NSSF
Who will pay the share?
Company
Employee
Company & Employee
Send Message
