Group Medical 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
Name of the Proposer
2
Postal Address
3
Telephone No
4
Fax No
5
E-mail
7
Business/Trade
Employees to be Insured
Total No of Employees
Total No. of males
Total No. of Females
Total No of Dependents
Total No. of males
Total No. of Females
Category of the Employees:
Note:
Please provide us with the list of the employees and their dependents showing their Age, Designation and Nationality.
Benefits required
(a)
In Patient Treatment only.
(b)
Out Patient Treatment only.
(c)
In & Out Patient Treatment.
Limits required: (Per person per year)
(a)
Dhs.50,000
(b)
Dhs. 100,000
(c)
Dhs. 200,000
(d)
Dhs. 300,000
(e)
Dhs. 500,000
Geographical Area required:
(a)
U.A.E Only
(b)
U.A.E. + ARAB COUNTRIES + SOUTH EAST ASIA
(c)
WORLDWIDE excluding USA and CANADA
Room and Board limit: Dhs
per day.
Pre-Existing Conditions:
(a)
To be deleted.
(b)
30 days waiting period
(c)
60 days waiting period
(d)
90 days waiting period
(e)
180 days waiting period
Deductible/Excess Dhs.
per person per claim.
Additional Optional Covers:
(a)
Maternity
(b)
Dental
(c)
Optical
(d)
Repatriation
Declaration
We declare that all employees proposed for insurance are in good health and none of them suffer from any chronic diseases.
select
Yes
No
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