Group Personal Accident Proposal Form

Name of Proposer/Organization*

Phone*

Email*

Address*

Type of Business

Place of Employment

Particulars of the Group

LIST OF EMPLOYEES
Please ATTACH a list of all Employees to be Insured in the format below:

No: | Full Name | Age | Designation | Annual Salary | Sum Insured

Type of cover required (Please tick if opting)Death onlyPermanent Total & Partial disabilityTemporary Total disability (Weekly benefits)Medical Expenses per head in hospital required