Individual Life / Critical Illness / Personal Accident Proposal Form

 

          

Name

 Date of Birth:

Nationality

 Gender Male  Female 
Email Contact Designation
Mobile No. Company Name(To consider your submission, please provide with your company name)
Annual Salary   $ Desirable  Assurance Face Amount $
Mode of Payment   :   Annual  Semi Annual Quarterly Expected Annual Premium $
 
Life Insurance

Yes  No

    
Cover Required

Term Life Policy   (Death to any  cause)

Investment Scheme

Education Plan

Mortgage Scheme

  
       
Personal Accident Insurance    Yes  No    
Cover Required

Accidental Death (AD)

Permanent Partial Disability  (PPD)

Permanent Total  Disability  (PTD)

Temporary Total  Disability  (TTD)

Repatriation Expenses

Accident Medical Expenses

 

    
       
Critical Illness Insurance    Yes  No    
 

Other Details if any:

 

 

      
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