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