proposal form dha
DESCRIPTION
New India Insurance FormTRANSCRIPT
PLEASE SELECT YOUR TPA:
1 YES NO
2 YES NO
3 YES NO
4 YES NO
5 YES NO
6 YES NO
7 YES NO
8 YES NO
9 YES NO
10 YES NO
PLEASE
Would you like The New India Assurance Company Limited to send health related SMS and Mail? YES NO
The validity for this proposal is for 1 month from the date this application form is filled up.
Note: Please enclose Medical History Form, Passport copy with Visa page & color photograph.
SIGNATURE
All members of the family to be covered under the same plan only.
RELATION
(INSURED/
SPOUSE/ CHILD)
GENDER
(M/F)
DOB
(DD/MM/YYYY)
SUM INSURED : AED 1 MILLION
CONTACT DETAILS:
LANDLINE / MOBILE
FAX
*All requested details are mandatory.
ADDRESS
VISA ISSUED FROM: ABU DHABI / AL AIN OTHER EMIRATES
MARITAL STATUS -
MARRIED
Excluding USA & Canada
Including USA & Canada
If opting for EUROMED PLATINUM, please select from the below options:
SUM INSURED : AED 150,000
GOLD PLATINUMRI’AYAH
RI’AYAH PLUS GOLD PLUS
THE NEW INDIA ASSURANCE COMPANY LIMITEDAPPLICATION FORM FOR EUROMED SERIES
DATE:
Sr. No.
PLAN SELECTION:
MEMBER NAME NATIONALITY
PLATINUM PLUS
SUM INSURED : AED 500,000
DIAMOND
DIAMOND PLUS
DUBAI
SUM INSURED : AED 250,000
Rais Hassan Saadi Insurance Agents L.L.C.: Chief Agents For Dubai Northern Emirates
P.O. Box : 5701, Dubai, UAE Tel: + 971 4 3525563/3522539, Fax : +971 4 3518544
E-mail : [email protected] Website : www.nia-dubai.com