About Us

Personal Details
Company Name : *
Nature of Business : *
Telephone : *
Fax :
E-Mail Address : *
Benefits
Sum Assured : 12 Months 24 Months 36 Months 48 Months
Death Benefit : Natural Accident
Ancillary Benefits : Permanent total disablement due to accident
Permanent total disablement due to sickness
Permanent partial disablement due to accident
Total temporary disablement due to accident
Workmen’s Compensation Cover
Medical Expenses due to accident
Repatriation : Yes No
Other Requirement :
Claim History
   Year Amount History
   2007
   2008
   2009
   Details of any claims over KD 5,000 and their status
   
Data to be provided along with this form
     List Containing: (Saved In a floppy disk) :
     Signed By Client :
     Signed By Agent :
     Date :
For Office Use Only
   Recieved Date :
   Remarks :




   Presented Date :
   
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