- 1 - APPLICATION FORM & QUOTATION REQUEST APPLICATION FORM & QUOTATION REQUEST 1- Your Personal Details Name: ……………………………...…………… Nationality: ……………………….……………. Dept/ Section: …………………………………. Designation: ……………………………………. Office Tel No: ………. Mobile No: …………… Fax No: ……… Residence Tel No: ……..…… Bank Details: …………………………………… Account No: ……………………………………. Address: ……………………………………….. …………………………………………………... ………………………………………………….. ………………………………………………….. ………………………………………………….. Contact Name: ……………………………….. Position in Company: ………………………… Telephone: ……………………………………. Fax: ……………………………………………. Email: ………………………………………….. 2- Eligibility/ Premium Payment Employee family status: FamilySingleParentCouple…………………………………………………………………. Will the insurance apply to employees only? YesNo……………………………………………………………….. Are the employees’ dependants to be covered? YesNoOther……………………………………………….. Will the Company be paying the premium for: - Employees only? YesNo- Employees and dependants? YesNo- Otherplease specify: ………………………………………………. ………………………………………………. 3-Premium Payment Frequency Please indicate your preferred method of payment: Annually6-monthly(5% administration charge applies) ……………………………………………………………….. 4-Previous Claims Experience a) Have you previously been insured for medical benefits? YesNo…………………………………………………………………. If yes, please give names(s) of previous insurers here and attach previous benefits and renewal date details: ……………………………………………………………………… ……………………………………………………………………… ……………………………………………………………………… ……………………………………………………………………… ……………………………………………………………………… ………………………………………………………………………
1- Your Personal Details Name: ... Nationality: .. Dept/
Section: . Designation: . Office Tel No: . Mobile No: Fax No:
Residence Tel No: .. Bank Details: Account No: . Address: ..
... .. .. ..
Contact Name: .. Position in Company: Telephone: . Fax: . Email:
..
2- Eligibility/ Premium Payment
Employee family status: Family Single Parent Couple .
Will the insurance apply to employees only? Yes No .. Are the
employees dependants to be covered?
Yes No Other .. Will the Company be paying the premium for: -
Employees only? Yes No - Employees and dependants? Yes No
- Other please specify:
. .
3-Premium Payment Frequency Please indicate your preferred
method of payment: Annually 6-monthly (5% administration charge
applies)
..
4-Previous Claims Experience a) Have you previously been insured
for medical benefits? Yes No . If yes, please give names(s) of
previous insurers here and attach previous benefits and renewal
date details:
- 2 -
APPLICATION FORM & QUOTATION REQUEST
b) Please provide the following information (if available) c)
Please provide separate details of any claims which individually
exceed USD 10,000: 6- Details of Membership: 7- Data Protection:
The Company complies with the principle of data protection and
declared for the safekeeping of data and will only use the
information contained on this application for the purposes of
advising on healthcare and related products.
Year
.
Total membership covered
Premium paid
....
Number of Claims
Amount of
Claims .
NAME
....
SEX
...........
...........
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DOB
NATIONALITY
PROFESSION/ RELATION
.
STATE OF QATAR ID # ....
- 3 -
APPLICATION FORM & QUOTATION REQUEST
9- Declaration by Employee or Authorized Representative:
I declare that to the best of our knowledge and belief the
information given herein is true and complete. Name: Signature:
Date: (DD/MM/YY)
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