e-mail:*
Insured1
Name:
Age:	/years/
Occupation:
Period of insurance:	/years/
Insured2
Name:
Age:	/years/
Occupation:
Period of insurance:	/years/
Insured3
Name:
Age:	/years/
Occupation:
Period of insurance:	/years/
Insured4
Name:
Age:	/years/
Occupation:
Period of insurance:	/years/
Insured5
Name:
Age:	/years/
Occupation:
Period of insurance:	/years/

Covered risks:
1. 2. 3. 4. 5. 6. 7. 8. 9. 10. 11. 12. 13. 14. 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. Birth. Marriage.
Please list the risks which you want to be covered from 1 to 14:
If you have any preferences for an insurance company please let us know:

Please let us know what premium is acceptable for you: