Proposal Form for Comprehensive Personal ... - New India Oman



[pic]

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 : ______________

................
................

In order to avoid copyright disputes, this page is only a partial summary.

Google Online Preview   Download