PERSONAL ACCIDENT PROPOSAL FORM

    Name of the Proposer

    Name of Beneficiary






    Sum Insured Required

    Type of Cover Required (Please tick the required options)
    i. Death Onlyii. Permanent Total & Partial Disabilityiii. Medical Expenses in Hospitaliv. Repatriation Expenses
    Please specify limit required for Medical Expenses in Hospital

    Please specify limit required for Repatriation Expenses