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INDIVIDUALS
CORPORATE
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PREVENTIONS
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ABOUT UFA
UFA PREVENTIONS
INDIVIDUALS
CORPORATE
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COMING SOON
UFA
Proposals
Fire Proposal
Personal Accident Proposal
Motor Insurance Proposal
Residential Fire Proposal
Term Life Proposal
Personal Accident Insurance Proposal
The Applicant
First Name
Last Name
Father
D.O.B
1944
1945
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Marital Status
Single
Married
Widow
Gender
Male
Female
Occupation
Building
Street
City
Region
Phone No.
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
1- What is your height?
Weight?
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.
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