Fin301 Life/Health C/A Application

Health Authority - Abu Dhabi Health System Financing

Insurance Company Letter of Request to be an Authorized Health Insurer participating in the Health Insurance scheme in the Emirate of Abu Dhabi

To: Director of Health System Financing Division, HAAD

Dear Sir,

We, ……………………………………………………… practicing in the UAE as an Insurance Company, request approval for our company to be authorized as a Health Insurer in the Emirate of Abu Dhabi.

We hereby agree to adhere to the Health Insurance Bylaws & regulations of the Emirate of Abu Dhabi along with all current and future requirements of HAAD, committing to provide health services in accordance with professional and ethical standards.

We hereby confirm that all information submitted and attached to this request is correct and complete, and we reiterate that we have submitted all the necessary supporting documents with this request. We agree to submit for review all our records and documents upon request.

Yours sincerely,

Mr./ Mrs. …………………………………. title: …..…………………… is hereby authorized to represent our company and sign the documents as necessary

Signature: ……………….………………………. Date: / /

Company’s official seal:

- C2- APPLICATION FOR AUTHORIZATION To be an authorized Insurer participating in The Health Insurance scheme

To HAAD Health System Financing Division;

Date of application: ______

Company license no.: ______(Ministry of Economy)

Company license no.: ______(Department of Planning & Economy – Abu Dhabi)

______(Name of applying insurance)

Mailing address: ______(City) (Emirate) ______(Office phone) (Fax number) (E-mail)

We hereby apply for authorization to offer the types of health insurance plans listed below in the Emirate of Abu Dhabi:

Basic compulsory plan:______

Enhanced plans:______

We hereby confirm that all information submitted with this request is correct, and we reiterate that we have submitted all necessary supporting documents with this request.

(Company seal) ______Insurance Company Manager’s Name & Signature