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

EMAIL

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 : newindia@nia-dubai.com Website : www.nia-dubai.com