Life Insurance Proposal Form   Please select the country/city where the form is to be submitted -Select Country- Kuwait Lebenon Saudi Arabia U.A.E 1 General Information Name of the Proposer Full Address : Residence : Business : Telephone No : Fax No : E-mail : 2 Profession or Occupation : a. Is your job administrative or clerical select Yes No b. Do you work manually without machinery select Yes No c. Do you use machines during work select Yes No 3 Schedule of Covers and Limits a. Life : Permanent Disability : Plan : b. Personal Accident : Permanent Disability : Weekly Indemnity : Medical Expenses : Passive War : c. Hospitalization : Class : Out - Patient : 4 Sport activities and Recreation : 5 Nominated Beneficiaries and Relations : 6 Height : 7 Weight : 8 a. To what extent do you consume Alcoholic drinks :    b. Have you ever been treated for alcoholic habits or advised    by a doctor to reduce your alcoholic consumption or smoking 9 Give Name of your usual medical attendant 10 Address of your usual medical attendant 11a. Have you Consulted any doctor or specialist during the past five years ? select Yes No b. Have you ever had an X-ray, ECG or other special investigation ? select Yes No c. Do you have any physical deformity defect ? select Yes No d. Are you under any medical treatment ? select Yes No e. Has any member of your family died from heart disease or ever suffered    from tuberculosis, diabetes or mental disease or cancer ? select Yes No 13 Schedule of family members: Name Middle Last Date of Birth Relation Sex Married/Single Day Month Year Male Female Married Single Male Female Married Single Male Female Married Single Male Female Married Single Male Female Married Single Male Female Married Single Male Female Married Single                   14 Have you or any one of the dependents had :   a. Surgical operation or suffered from any serious illness, disease, accident or injury ? select Yes No b. Epilepsy, Paralysis, Nervous breakdown, Fainting spells, nervous or mental trouble ? select Yes No c. Habitual cough, Tuberculosis, Disorder of heart, Asthma, lungs or throat affection or any disease of the eye or ear ? select Yes No d. High or low blood pressure, Goiter, Tumor, Cancer, Disorder of blood, Glands or Skin ? select Yes No e. Any affection of the kidneys or bladder, Rheumatic fever, Rheumatism, Gout or Diabetes ? select Yes No f. Varicose veins, Piles, Hernia, Syphilis or Gonorrhoea or any form of veneral disease or any physical deformity defect ? select Yes No 15 Additional Remarks : 16 Policy Inception date : Declaration The indication above shall form the basis of the insurance contract. I hereby declare that I have answered the questions myself and that the answers are true and complete, and have given with the knowledge that an incorrect or incomplete answer may result in the insurance being cancelled. I authorize physician, hospital or nursing home and insurance institution to provide any information to the Compagnie Libanaise d'Assurance S.A.L. that considers necessary in connection with the insurance now applied for.   [ To download the form please right click the Download button and select "Save target as" and Save.]  Download the Form           Download Acrobat Reader Top