Proposal Form for Comprehensive Personal ... - New India Oman
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The New India Assurance Company Limited
P.O.Box 2907, Ruwi, PC 112, Sultanate of Oman
Proposal Form for COMPAS (Comprehensive Personal Accident Security)
ELIGIBILITY
This Insurance scheme is available to all residents of Sultanate of Oman between the age group of 18-60 years whilst stay in Sultanate of Oman having valid visa.
IMPORTANT NOTICE
This Proposal Form must be completed and signed by the proposer disclosing all material facts.
• A material fact is one of that is likely to influence the acceptance or assessment of the proposal.
• Non-disclosure of material facts, misleading information, fraud or non-cooperation by the Insured will make the Policy void.
Plan opted – please mark (√ )
COMPAS SILVER COMPAS GOLD COMPAS PLATINUM
1. PERSONAL DETAILS :
Name ( Mr /Ms ) : _____________________________________________
(BLOCK LETTERS)
Father/Spouse Name : _____________________________________________
Sex : Male _______________ Female _________________
Date of Birth : _______________________ Age __________________
Passport No. : _____________________________________________
Resident Card / I.D. No. : _____________________________________________
Type of Visa Held : _____________________________________________
2. Permanent Address : _____________________________________________
_____________________________________________
_____________________________________________
Landline _________________ Mobile ______________
3. Local Address : _____________________________________________
_____________________________________________
_____________________________________________
PO Box: ________P.C._________Tel.No.___________
4. Profession, Occupation, Trading or Business _____________________________________________
(Please describe fully with nature of duties)
_____________________________________________
-2-
5. Name & Address of Sponsor / Employer : ____________________________________________
____________________________________________
____________________________________________
6. Period of Insurance : From _________________ To ________________ (2 years)
7. DECLARATION
I hereby declare that the above answers are true to the best of my knowledge and belief that I have disclosed all particulars effecting the assessment of the risk. I agree that this proposal and Declaration shall be the basis of the contract between me and the Company.
___________________________________________________________________________________
ASSIGNMENT (if desired)
Note : If Policy benefit to be assigned, please complete the following :
DECLARATION FOR ASSIGNMENT
__________________________________________ do hereby assign the money payable by the New
India Assurance Company Limited in the event of my death to my _____________________________
(mention relationship with the Insured) Mr / Ms __________________________________ and I further
declare that his / her receipt will be sufficient for discharge to the Company.
Date : ______________ Place : _________________ Signature of Proposal : ______________
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