PROPOSAL FOR PERSONAL ACCIDENT INSURANCE GROUP
(For organisations based in United Arab Emirates)

Name of Proposer
Address
Telephone
Fax
       
Trade of the Proposer
     
Particulars of the group

Si
No

 Name Age Type of Job Sum Insured
1
2
3
4
5
P.S.A separate list may be attached if it is exhaustive.
         

Type of Cover requered

      Death only 
Death, Permanent Total and Partial Disability 
Death, Permanent Total and Partial Disability with
      Medical Extension 
         

Proposed Period of Insurance

         

Previous Insurance Details  

I/We certify that the above information is true to the best of my/our knowledge and belief
            
Date
Place

 

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