"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"
Full Name    
Date of Birth   Age
PO Box Postal Code
Area Country
Phone No. Fax Number
GSM EMail Address
Details of Insured
Full Name Gender
Date of Birth   Age
Home Country Residing Country
Phone No. Fax Number
GSM EMail Address
Passport No Expiry Date
Labour Card No   Expiry Date
Weight (kg's) Height (cm's)
 Cover Details
From Date: (dd/MM/YYYY) * To Date: (dd/MM/YYYY)
* Cover will commence only after 48 hours from now"
Insurance Required
 Sum Assured  Term
Beneficiary Details
Beneficiary Name Beneficiary Relationship
Additional covers(Optional)
PA Required
Repatriation Required
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 I am the proposer/Employer of the domestic help (Insured), and I having read the details as contained herein above and that I request NATIONAL LIFE & GENERAL INSURANCE CO.SAOC to issue the policy based on this proposal in the Insured's name and that I understand that this request and declaration and any other statement signed by the proposer / employer mentioned herein before in connection with this proposal shall be the basis of proposed contract of life assurance policy.


I also declare that I shall Indemnify and hold harmless the insurer against any claims arising out of negligent actions, Omissions, willful omission and Commissions or providing with false information with regard to the Insured.