Personal Accidents Application


Applicant Name
First Name
Middle Name
Last Name
Sex
Date of Birth (dd/mm/yyyy)
Place of Birth
Register No.
Marital Status
Profession
Exact Occupation
Is your job based on machinery?
Is your job based on manual work?
Business Address
Home Address
E-mail Address
Mobile number
Business Phone
Home Phone
Address where correspondance should be sent


Schedule of Benefits
 Sum Insured
Death
Permanent Total Disability
Permanent Partial Disability(as per continental scale)
N.B. : The sum insured of permanent diability (Partial and Total) should be equal or less than the sum insured of death. Otherwise, application is considered void.


Details about beneficiary
First NameMiddle NameLast NameRelationshipPercentage
1.
2.
3.
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5.


Answer below questions by using Yes or No. If your answer is yes, please give details.
Do you suffer from any physical handicap, disability or bodily deformity due to illness or injury?
Do you suffer weakness in any of your five senses?
Are you now under medical treatment or undertaking medication on regular basis?
Do you engage or have you engaged in any of the following hazardous activities?
Private Flying
Skiing
Motor Racing
Parachuting, Mountaineering
Diving, Climbing
Other (specify)
Has an application of an insurance (Life, Personal Accident, Hospitalization) ever been declined, deferred, withdrawn or accepted with a loading or on special terms?


Do you have any other Personal Accident and/or Life Insurance with AROPE or other Insurance Company?
Company NameSum InsuredType of Insurance
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I declare that the contents in this application 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 (if issued). I also engage myself to notify the Company of any change in the information mentioned above.