Application for Group Personal Accident Insurance

Insured
*Name:Business Description:Period of Insurance:
Address:
Customer Details
*Contact Person:*Phone:Fax:*Email:
Interest Insured
NumberSum Insured per personMedical Expense
No. of expatriate staff:US$ US$
No. of office staff:US$ US$
No. of workers:US$ US$
No. of other staff:US$ US$
Territorial Limit


History
Currently, does the proposer have any group personal accident policy?
Claim Experience
Has the proposer made any claim(s) or had any accident(s) for the past 3 years?
Remarks
Go to Group Personal Accident Insurance page for more information.