Personal Accident Proposal Form

First*

Middle*

Last

First Name*

Last Name*

Relationship to the insured*

PO Box*

City*

Country*

Phone*

Mobile*

E-Mail*

Address*

Occupation of Proposer*

Place of Employment*

Average Monthly Salary

Date of Birth (DD/MM/YY)*

Height(cms) / Weight(kg)*

Nationality*

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*