The Applicant

Benefits Required

Currency:

A- Death, A Principal Sum of:

B- Permanent Disablement (Total & Partial) No Yes | Percentages of - A - As per scale of Disabilities

C - TEMPORAY TOTAL DISABLEMENT No Yes
Weekly Benefit of: For a period of Weeks Excluding the First Weeks

D- Medical Expenses No Yes
Up to

Supplementary Covers

Passive War Risk No Yes
Amount

Beneficiary & Relationship

QUESTIONNAIRE Questionnaire

Has your weight varied over the past 12 months?
No Yes

2- Does your occupation involve manual work?
No Yes
Are you left-handed?
No Yes
Do you use industrial machines while working?
No Yes

3- Have you any physical defect or deformity?
No Yes

4- Do you participate in any hazardous activity?
No Yes

5- Do you fly other than a fare-paying passenger on regular airlines?
No Yes

6- Has any applicant on your life, accident or health ever been declined, deferred or accepted on special terms?
No Yes
Please Explain:


7- What other personal accident insurances do you currently own?


8- Are you now under medical observation or undergoing any medical treatment?
No Yes
Please Explain:


9- Have you ever suffered from any serious illness, disease, accident or injury?
No Yes
Please Explain:


10- Does the weekly benefit required exceed 75% of your weekly income?
No Yes
Please Explain:


I Declare That The Statement In This Proposal Whether In My Own Handwriting Or Not, Are True And I Agree That This Declaration Shall Be The Basis Of The Proposed Contract Of Insurance. I Also Undertake To Notify The Company Of Any Change In The Information Mentioned Above.