Name of the Proposer
First*
Middle*
Last
Name of Beneficiary
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*