PROPOSAL FOR PERSONAL ACCIDENT INSURANCE INDIVIDUAL
(For persons based in United Arab Emirates)

Name in Full
Address
Telephone
Fax
       
Profession
     
Average Monthly Salary
        
Date of Birth
          
Details of Medical Problems, Physical Defects, Deformities, etc 
Type of cover required
      Death only 
Death, Permanent Total and Partial Disability 
Death, Permanent Total and Partial Disability with
      Medical Extension 
            

Proposed Period of Insurance

         

Previous Insurance Details  

          

Reason for change of insurance  

      

Previous Claims History  

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

 

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