"Designed for sponsors to take care of their liability towards expenses likely to be incurred on repatriation of their Expatriate"
*All fields marked in red are mandatory
Details of the Proposer
"Eligible only for residents of Sultanate of Oman"
Name Gender
Date of Birth Age
PO Box Postal Code
Area Country
Phone No. Fax Number
GSM EMail Address
Details of Insured
                                           Same as address of the proposer                  
Name Gender
Date of Birth Age
PO Box Postal Code
Area Country
Phone No. Fax Number
GSM EMail Address
Nationality
 Cover Details
From Date: (dd/MM/YYYY) * To Date: (dd/MM/YYYY)
* Cover will commence only after 48 hours from now"
Risk Details
Designation Occupation
Resident ID Passport No
Sum Assured Annual Income(OMR)
Residing Country
 
Beneficiary Details for Death benefit
Beneficiary Name: Beneficiary Relationship
Declaration
I, the Proposer / Employer hereby declare that

1. No application of the Insured for life or Health assurance has been declined, postponed or accepted with special terms or Restrictions

2. The insured has never suffered from spiting of blood or any chest disease or lung Infection, tuberculosis, gout rheumatism, heart, brain or urinary trouble, internal Disorders, asthma, cancer diabetes or any nervous or recurring disease

3. The insured has not suffered any sight or hearing impaired or infection of the Eyes or any ear complaint, perforated ear drum or any discharge of the ear.

4. The insured never had a fit or any kind of paralysis

5. The insured has not ruptured veins or varicose veins or physical defect or Infirmity of any kind

6. In the last 5 Years the insured has not suffered from any other illness or accident for which He/She has received any medical attention.

7. None of the relative of the insured suffered from any tuberculosis disease within the last 5 years and Nobody where the insured is living has suffered /suffering or recovering from any contagious or infectious disease

I declare that the information provided above is true and correct in all respects. I understand that the information contained herein shall be the basis for any decision of the Insurers to provide the insurance to me and this proposal form shall be a part of and shall deemed to be incorporated in the insurance contract finalized in this regard