Company:
e-mail:*
Contact Name, Address & Tel. No.:

Type of Business:
Is your business connected with Hazardous activities? (Yes/No)
Does your business comply with all relevant regulations?(Yes/No)
Are all your Employees fully trained to deal with any hazards?(Yes/No)
Have you had any accidents in the last three years? (Yes/No)
Did any accident result in death, if so how many?
Did any accident result in permanent disability, if so how many?
Total Number of Insured Persons:
Administrative Personnel:
Manufacturing Personnel:
Others:

Covered risks:
1. 2. 3. 4. 5. 6. 7. 8. 9. 10. 11. 12. Survival of the Insured. Death of the Insured. Death of the Insured due to an accident. Permanent disablement due to an accident. Temporary disablement due to an accident. Temporary disablement due to an illness. Expenses for medical examinations and check-ups. Expenses for hospitalisation. Expenses for medicines prescribed by a physician. Dental expenses. Transport expenses in case of accidents, serious illness or death. Hospital Daily Benefits.
Please list the risks which you want to be covered from 1 to 12:
If you have any preferences for an insurance company please let us know:

Please let us know what premium is acceptable for you per one Insured:

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