NQ Ulosd Daman. Abu Dhabi Basic Plan - Small Groups Basic Plan (Less than 11 Employees) Rosier tated Trade License Power of attorney List of employees (MOL) Passport copy . Visa copy Emirates 1D _ Labour contract Salary certificate . Photograph 10. Original Health Insurance Continuity Certificate |__11. Signed and stamped Group Application Form and Letter of Acceptance | is |e |sJor]un|s|uol Slcilocaodd Notes: 1- Emirates ID copy for the authorised person. 2- For new members, provide a photograph, Emirates ID, and Original Health Insurance Continuity Certificate from the previous insurance company of the policyholder or the member. 3- New member should provide unified application form for visa and EID along with Emirates ID undertaking letter 4- For enrolling new-born babies below 180 days, you can submit a birth certificate if you couldn’t provide an Emirates ID and passport, along with Emirates ID undertaking letter. 5- Labour contract stamped by the Ministry of Labour, not older than two (2) years. 6- Provide a Salary Certificate form that is available online at www.damanhealth.ae. You can find the form by going to the end of the main page at the (FAQ's and Download Forms)>(Download Forms)>(Forms for Abu Dhabi)>(Abu Dhabi Basic Plan - salary certificate for in dividual). The form is valid for one month and it should be stamped, dated and signed. 7- List of employees issued by the Ministry of Labour, not older than one month. 8- Undertaking letter can be collected in case the visa has expired (more than 30 days). 9- Undertaking letter can be collected in case the trade has expired more than 30 days but less than one year.NB VYlosd Daman. VV ge BN! Bypdrall SE Slegarme lull absil gobi bye UE gi gi Sy alaiel ye ge .Y SLeiell 3 calelall elawh ass 1 Ssrlbge £0 | 491 5g .0 ayia | OOOO} deal gfe 9 po V | : ily Bale A dyads igo A | peal all yyy alg.) se | Biya bsg lal de a ptall yas ety GHG.) | soba Shall gL Ad pall art) ASLUY! Aoggll -) call patel Sly 0 Ay AN aay dtl yey ABUL dag gs AS code Stal 1 4883) Cole os gall Haga ddd gad Qe ASLLeYl digglly AAU uo gall Cllall yo AS ST otal aS itall le Gay -T ashy sphaal ily af gqll Gilley Glial pe lef Deall Sle Ads Cow cgye VA+ pas Go oteel algal -£ doles dad gay cds ypay chagisne Cl Sale LALLY) gall lsd ages ae ASL LAY gg) ASlky Clb JLely Spall de cigail igh uo 44uyU gw oly gt Sad pals Bal doudle Jas Syljg ga dagises asl agic -0 Aovteall dg JI JBI JOS 2 Aitanall Je Jgaoull SiSay .www.damanhealth.ae deal jas! -1 Forms for Abu )<(Download Forms) < (FAQ’s and Download forms) J! Gauls Anas)! u Dhabi Basic Plan - salary certificate for individual)< (Dhabi 4578 a p42 Stal lo Jasll lig yale Jlaall ALS -V Hise ily lage + Ge 5 BAH) lel Ras ode lg Je Gages Gllas eld -AGroup Application Form Fe Ge onl Ub Request Reference No ; A. Company Information Seine — Spwetag Ruy pues Annercuis (Grprtave wewaeay” Oe" CW-4EEELAYL reetememnginey Merl cca Ce Seeded ohiaDh gene = wc. (Adaress, Emirates and P.0 Box) AL | Dowel = Rcdae Toner. ere Sng! 8. For Groups with 10 or less employee-only for Ba! (Abu Dhabi) Plan (Applicable for female employees on oecrugese sey atory as Basines velopment Mager.» Company, oebae Nt A saterentsmadein wns appear hei es {ner declare natal nricuas to be eral renened under he Ban (ADU ubssnta Senet Pana eae or murat aca i es alia E10 cara for enlaren under 12 months*** ‘Document shoud oe sumed mthin a acinar of 30 30 Betas Jed Name: as doo Te rnc Sioa and same sto Hil samanneatinas saagsneo | totNa Ulosd Daman. Letter of Acceptance ~ Basic (Abu Dhabi) Pian gota ali ~ dig) Ye dadlgasf DLs) (bse!) Process Reference Number: uae me ete dy LOA Reference Number: SE ea aati ey ey jew Policy Dienewal Policy Casi prea A. Policyholder Information iy!) ole Sleglas | Policyholder Name: Zid Ends csicdl decsk; Aig ote pal Customer Number ae ae eee el Policy Type: kip es Policy Effective Date: Policy Expiry Date: Policy Period (In years) No. of Members including the Policyholder if applicable (Members) Total Premium (AED): (eat) Bag ole aah ly eat coon buat Hs Spake Ye yh gh eo (Lae) Slo} Phone Number: 22s 643 3904 news a Mobile Number: 050 4b 0127 Bad IG dy Fex Number: ee = ae cae Zieds\o volumelvic oe ‘ia at Malling Address ‘ if 3 satolye ce: _ALu Dhaai Lee Sass en ee erases ae Contact person: Wid E\iwads 3 ‘afl pA pl esignation a 3 7 7 Fae sri, Rega Stipe Mamgie AS B. Terms and Conditions This Letter of Acceptance ("LOA") isa legally binding contract entered into by and between the National Health Insurance Company - Daman PISC ("Daman") and the policyholder Identified in Section I above, (*Policyholder” (collectively, the *Parties"), In consideration of the promises and other terms set forth below, the Parties agree as follows: 4) The Policy. Upon the Policyholder’s execution of this LOA ‘and the Basic (Abu Dhabi) Plan Application Form (to be attached to this LOA as Schedule 1), Daman shall issue to the Policyholder health insurance coverage for the Policyholder's employees/ sponsorees ("Members") through @ Policy comprised of: (a) the Policy Wording which is available in Daman website; (b) the Schedule of Benefits set out in Schedule 2 of this LOA; (c) any riders, amendments or special agreements set out in Schedule 3 of this LOA (if applicable); and the terms and conditions Of this LOA. The Policyholder shall inform the Members of all terms and conditions of the Policy. 2) Policy Period. Uniess terminated earlier pursuant to the termination section set forth in the Policy Wording, the Policy shall commence on the Policy Effective Date as set ‘Out in Section I above and shall automatically terminate by Allg agi Bb Ballon S ew pla yg aten Deke Spel gh Bay fe Miya Dn gs 3 ("Olea") gpg Slade pall lea So) (day obo") atl He Si gi tlle apa 5) og tly ae jl eat le yada SAS Je Aga Lg ol hs ae aN Hig) Je ya ay Bb) (Bal) ga SN aia gee Sl coal gue cat ss laa po) pe — nd Ha oa ge 05S Hay DE Go (Las) yi age Ea te (0) lad JaiSY Bye oe Me Upanll Sang aa ig) sa La de aig eT 5, Ustal a! Se RyalDy oo Ty Upanls oN CL src (de ala igh Je AID by 9395 9fard al ola ph Bigg on byt y yuna BY ote 8b IST AY ad ge He BUA cy Lg ha 9 9l Stl yada Oe a coy BE cle gS 9 gl fe coy ge Jan i pia ag B91 ea ” 0 fn the Policy Expiry Date as set out in Section | above sen 3) Premium Payment. Notwithstanding the condions —g+0-1 ly iyStad DLN Aa yl SL3Y) MN ge.) Seen i fhe frum se forth in aria 65 of ve ay 1. of oh gal cuit pl T.- ve Nal po fccetive, Regulations Ne, 25/2006 of the Abu Dhabi “Luar aiisc aipeead caphom goacy eal Health Insurance Law No. 23/2005 and as set out in the a ; ‘| Policy Wording, the following provisions govern payment ©9 Wa ete Se Ol «SL ew fad SOE alba oS SL () Of the premium: (a) unless there isa genuine cispute MSI ME des Gl 91 AW ol Saal RS etween the Parties, the Policyholder shall pay the Total g-U¥! gatial) cult ibe quad aie RAS! Cole gu yaa! Premium as set out in Section 1 and is based upon the a3 chal Je suas sul Aye al gyone (-) doo) umber of Members provided by the Policyholder at the ub o« ite aad Jaf ia! (c)stgh ola gus il Wiad time of submission of the (ABU Dhabi) Plan Application slau iB ab hel JAS 0 (2) led Sg obs Form; (b) the Total Premium is subject to change based fn further requests to include adeltional individuals under damanhealth.ae MEMBER CONFIDENTIAL | 0787300 | 40f2: (c) the Total Premium is payable in advance by the Policyholder to Daman; and (¢) the Total Premium is non-refundable. 4) Accuracy of Information. The Policyholder shall verify the accuracy and compieteness of all. information furnished to Daman in connection with this LOA and the Policy. The Policyholder may not make any corrections to, any information connected to enrolment or renewal data, ‘especially member cancellation. If Daman has reasonable nds to believe that or failed to disclose a LOA or the Policy, invalidate this LOA and Policyholder Services covered under the Policy: (c) report the Policyholder to the Department of Health; and (4) pursu: all available legal remedies, including relief through the Civil and/or criminal courts of the Emirate of Abu Dnzbi 5) Representations & Warranties. The Policyholder represents and warrants that: (a) all_ information submitted to Daman in connection with this LOA and Policy is true, accurate and complete; (b) ail bbe enrolled under the Policy are “the Policy; (b) hold lable to reimburse Daman for ail health the Decree 83/2007, Circular 26 and Circular 39 0 ‘of Abu' Dhabi and Members to be enrolied under this Policy Any notices sent in connection wit must be addressed to: Chief Commercial Officer National Health Insurance Company - Daman P3SC P.O Box 128888, Abu Dhabi, United Arab Emirates Tel: + 971 2 614 9555 Fax: +971 2614 9816 Policyholder ‘AS per the information set out in Section A above. 7) Taxes. The Total Premium is subject to Value Added Tax (VAT) and any other taxes, from the date of implementation of VAT or such other taxes in the UAE, as er the applicable laws and regulations and Daman reserves its right to collect the same from the Policyholder In addition to the Total Premium. Riders and/or Revised Policy Information (it applicable). Any amendments to the LOA or the Policy shall not have effect unless agreed in writing by the Parties and shall be attached to this LOA es Schedule 3, 9) Save to the extent that terms are defined in this LOA, all terms and expressions used in this LOA shall have the meanings ascribed to them in the Policy Wording, In the event of any conflict between the Policy Wording and the LOA, this LOA shall prevail. The Policyholder acknowledges that he/she has received, understands and agrees to the terms of the Policy, and it particular such conditions which entitle Daman to terminate, exclude liability or void coverage under the Policy. Note: For Abu Dhabi (Basic) Plan Policy wording, please visit www.damanhealth.ae Signed for and on behalf of the Policyholder [Insert name of Policyholder] (3) i= ma! SLs!) BI ale ce Uy Name of Signatory/gSyal at Tile faba at Date/ei 8) Signature/es2 I camanneath.2c Ne Ulosd Daman. Bipatoleglal (hg dbs geaelAA I oLoge aglaals ¢) O09 ad Ligh Jo Uys UL 9 ang leat oa! Ulan Joma le gan a A oe Say ote epee ad ad G5 el A ASL: cite Shas pi 0 Fle Sign oe para ly USN bya Aig asp Gee (0b Aye 9 ta AB Cote soluyal y crktaan 0) GE ily UG 9 deyh ALI SG Gleal Antal Olglads 5 ear (0) lay Sage lglan pcan dig CA clade 02 SB) TV hy meal 9 T+ -VIAT dy ins ¢geeat Ly (2) dein gD ee BL 8 Biel dias GToaky 7 A ls Gayla aie 2 ipa splay Ua oylasyl aby oblast 1) Splat agg gt ya Etat Old gral laa ue) St shag yh AMAA cual Sys avi Tyeha00 susie sav Taye esi Scots DIA pal ja bag Slgleh ak Sh tha gy Blah anal Joy La gay Sad Y) Up Jess ciya Alf hawt Ah ye Gls ol oe BW Glee Bay gts ll Uy Baal Eel LLY DLN Jl! LAHAYE Bag old gad le at ABs Je OM rd Ol) Mg Slagle date Vy Cline A) Fe oa las it I Sy OS 9 Sg de daily UL 98a gh Je lye GIST Une Giga sabi oo pl 0S Ag Je Dal Uy al Lalla yer 4) de Haga ey PES! ray Reg ya Qa W983 ue Gaal Bag ap galas al Ul gh eh ope BE Ge aiiyay gy ake GIN (Poke AGH" Nya J Ah a Al la” Ga il dey ois aaa A at taaagt aed a dag aan Bal gt eal ol 9 ya de Up inde www damanhealn.2e 2iS5) siya (On behalf of the National Health Insurance Company ~ Daman (P3S¢) Cth Ola Grell Ola Lab gh Sol os ay Dateless MEMBER CONFIDENTIAL | O7879ROD | 2012VOLUMETRIC [On company letterhead] (SA by de} eS Date: Role abel pai pa pean ae ‘Abu Dhabi <. a United Arab Emirates: oe , ear Sir, Sy any le pL Salary Certificate ike With respect othe eawat ‘application for the Basic (Abu Dhabi) Plan, {hereby declare Bp Je el a at eal i ns that 1+ Alinaraduas intended be evoe/renened (Choose sj In aes ten 4 one) inthe Basic Pan ae labia fr thease Pani vy, oy ears eet Se eon wh trl and reas a MEY Scyaa at po aE ee, the Heath Insurance Law No. 23/2005 and ite emer 3 soem Executive Regulations No, 25/2006, 2. Abindwiguals tended to be encoted/renened (COS 3:5 SA ap npc spleen 2 ong) inthe Basic Pan are earning total manta salaries. 4 oan ys ttag ee wthin/up to AED 4,000 wn accommodation cr osm yee 5,000 without accommodation. . are 3 Alicia ol aed rescence vis sued rom the 5+ yi La py 3 oe 9A ger 9 rire Abu Dhabi andor meet theaigityertene out udsiagat tay mala a tec sec outin the Law; ‘4+ The Jnformath stated in this document is true and a ie pvt ye) la babies a {erect and understand tat proving fare pap das j eee cone ye formation shall be considered vlaton of the Stayt ant ae Smee sl ga ue relevant health insurance reguations snd that Vine. ‘ian Company may ‘be held Table for these vuntree Satoments 5. The Ist of individuals to be enoled/tenewed (Choose én/ ph a3) salina U0ah guj) 2ne) under te Base Panis atachad asa sot conyte Quai a yktin Si-US Map) Renee the email dated fineett DaITEED Base und ule Msg 46-3 19s hard com/CD. indwwas mantonedin te atacheg Si Si 8 oe V9 3A Ha ‘ist are employed the company named below. © sith fd Esa gla aN gE & The asa number of ingividval tendad 9 be tin Jagat /ashn Gniaad 6 enrolled renewed are (at) 1s (Signature) sg oh Kind E\undi. 2 ‘reer Name} Giaser Te) umetei Al Ferdous Tower, Floor No: 18, Office Contact :02-643324 Email: info@volumetricae : lam Street, Al Danah- Zone 1, Ios 1A Saba Se AT Dena Website : wirw.website.com Abu Dhabi, UAE.\ / VOLUMETRIC [On company letterhead] The table is to be completed if salary certificate is submitted as hard copy to Daman. cate: 19/12/2023, Name of Company: Volumetric Member list ~ individuals to be enrolle under Basic insurance policy. EID No. pee (5S ds Je] yy A AN pt A JON Ups ies 2 ee cei A saad ae ore) coy ieee ea fe Al Ferdous Tower, Floor No: 18, Office No: 7, Al Salam Street, Al Danah- Zone 1, Abu Dhabi, UAE, Contact: 02-6433224 Email + info@volumenic.ae Website : www.volumetric.aeInstructions for submission of salary certificate 1. All fields in completed. 2. The salary certificate must be typed and submitted on company letterhead. 3. If the member list is submitted as a soft copy excel sheet from the client, it should be attached with a signed copy of the salary certificate to the email that is sent to Daman. The date on the excel sheet should match the date of the letter. The salary certificate should be stamped and signed by the authorised signatory. 4. If the salary certificate is submitted as 2 hard copy, the member list must also be submitted with the letter. Each page of the. salary certificate and member list should be stamped. 5. If the member list is submitted to Daman ‘on CD, the CD should be labelled, stamped and signed by the authorised signatory. 6. Email should be sent to Daman by the authorised signatory. 7. Original version of the above letter to be submitted as a hard copy to Daman within 5 working days of sending email (or when collecting the original signed copy of the Loa). 8. Excel template to be provided to the client. the document must be SS BSlge pps ge lala Up Sng G Bap api gee Beda A AS eed Je ele lias pation 2 Unie Je U5) AS hae AS pat SI] Bola) bye AS a Shy ol and all ow LS) late Ole I oe GU GAD a wo Sy sores Dla Gaul eo LS te de Ql Gilly BG A a ARS Tlie wT Cake ge dake Beat coyy ML! ge alae! AS gy ea Sy 5 AOD) gate ga Gales YPolasN LID eS 5 BS a ll a eel ag a shall Sed oe tle QS yilly NS go led ja ay ed oe 6 iySdal) Vaal) bdgad ULAR geal Cay Ge ee AUS pct Ole UI tel ayy BS Badge Shel G5 (Se! aie 3) Ja aol SLL (Aditya aso LeS| pial iyat Jean was tae 8