On behalf of myself and my dependents named under of this application, I, the undersigned, hereby:

1. Declare that, to the best of my knowledge and belief, the information provided in this application, whether in my hand or not, the above statements and particulars are complete and true and that I have not misstated or suppressed any material facts (a material fact is one which is likely to influence Tawuniya acceptance or assessment of this proposal. If you doubt whether facts are material, they should be disclosed).
2. Agree that the Company shall have no obligation under the Policy that may be issued to reimburse any medical expense incurred which is not covered or which exceeds the Policy limits and I shall be responsible to reimburse the Company for any such incurred medical expenses.
3. Authorize any representative of the Company to examine and investigate the medical record of all individuals named in this applicationfrom any physician, hospital or medical center.
4. Declare that I understand that submission of this Application does not bind me to complete the insurance nor the Company to accept, but is agreed that this Application shall be the basis of the contract should a policy be issued.
5. I note that the application and declaration only applies within the limits and coverage mentioned in “Visit visa” plan and its table of benefits.
6. Medical expenses incurred in the emergency cases and at non-approved provider(s) must be submitted with original invoices and doctors report(s) within 30 days of the doctor visit before reimbursement can be processed, as specified in the policy. The compensation will be subject to the reasonable rates that are applied in the Kingdom.