Page 1 of 5

Membershi p Mai nt enanc e For m ,.n| _ni u'.| .,,

Al l t he bel ow f i el ds ar e mandat or y, pl ease f i l l i n c l ear f ont
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Transacti on effective date
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Pl ease f ax t hi s page t o
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920 000 725
Contract Number
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Company Name
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TRANSACTI ON TYPE / ,n| ,i
Pl ease c hoose (f i l l i n) one of t he bel ow t r ansac t i ons:
All the below options require additional documentation (refer to general rules in
page 3). For any assistance on how to fill out the form, please read the guidelines in
the following pages.
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Add new born u'.| ; .,,c

Add dependent(s) of an insured employee _c,c cL,c 'cu'.|

Replace card(s)(lost/ Data correction) Employee Dependents u'L;| _|;i.| ) u'u _; - .'c,nc i.i ( cL,, 'n

Re-activating ui ,.c _nui o.'c|

Delete an employee ( Dependents will be deleted automatically) cL,,.| .'n| ) _'n,.| ,; .'n| i. (

Delete a dependent(s) only _c,c cL,c 'c .'n|

Employee Upgrade or Downgrade (and dependents) i'c cL,,.| Lni ;,. _ni

Transfer to new Branch ,| ,u C| cL,,.| _'uii|

EMPLOYMENT DETAI LS / cL,,.| .'i';
Current membership no (skip if new member)
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Gender
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Employee No.
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Name as per the ID ( First Middl e Last )
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Date of Birth (Gregorian)
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DD/MM/YYYY
Requested Level of Cover
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Iqama or Saudi ID
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Sponsor ID
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National ity
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Branch name
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Reason
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DEPENDENTS DETAI LS / 'n.| .'i';
Current
membership no (skip if
new member)
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Name as per the ID
( First Middle Last )
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Iqama or Saudi ID
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Date of Birth
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Nationality
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Please mark this box if you have more than 4 dependents to add and
follow step 3 in the guidelines (page2)
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I certify that the information given on this form and in any documents attached is
correct, complete and accurate. I understand that the information provided by me
maybe verified and hereby consent to such verification activities. I also understand
that providing false or misleading information may result in canceling the membership
and may be grounds for any legal accountability.
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Guidelines:

Thi s secti on provi des some gui del i nes on how to fil l in page
1. Depends on transacti on type, you get to fil l i n the
necessary i nformati on that sati sfy our requi rements. 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:
Transacti on type
Mandatory fi eld
number
Notes
Add new Employee
and Dependents
Employee only:
From 2 t o 10
Employee and
dependent:
From 2 t o 10
And
From 13 to 18
3 only if applicable
Add new born
1 - 4 - 7 - 8
From 13 to 18

Add dependents of
an insured employee
1 - 4 - 7 - 8
From 13 to 18

Replace cards 1 - 4 - 11
The fields from (2 to 10
for employees or from
12 to 16 for
dependents) will be
filled according to the
reason.

Example: if the reason
is wrong Employee
name, field number 2
must be filled
Re-activating
For Employee:
1 - 4 - 11
For Dependents:
1 - 4 - 11 - 12 - 13

Delete an employee
and Dependents
1 - 4 - 11
Delete Dependents 11 - 12 - 13 - 14
Employee upgrade
or downgrade
1 - 4 - 6 - 11
Transfer to a new
branch
1 - 4 - 10
In field no. 10, only the
new branch name
must 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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Page 3 of 5








The bel ow rules were desi gned i n compli ance with the
Council of Cooperati ve health Insurance (CCHI) and Saudi
Arabi an Monetary Agency (SAMA):

General rul es:

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 persons
incorporate 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 documentation
may 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 Condi ti ons:
A. Condi ti ons 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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Page 4 of 5





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. Condi ti ons of card repl acement (data correcti on- l ost):
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. Condi ti ons of re-i nstati ng:
A letter justifying the reason for reinstating the member.
A confirmation that the member doesnt suffer from any major
health condition.

D. Condi ti ons of del eti on:
Copy of the resignation letter must be submitted for Saudis.

In case of expatri ate members, they wi ll be onl y del eted
accordi ng to the bel ow:
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 a
confirmation 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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Page 5 of 5




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. Condi ti ons 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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