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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:
 


 

 
   
 
 
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