*All fields marked in red are mandatory
Details of the Proposer
Name
Resident Status	Resident of Oman	Visiting Oman
Resident ID No		Passport No
Gender	Male	Female
Date of Birth		Age
Occupation	Select Banking / Financial Cashiers Clerical Workers Doctors / Dentists Educational Institutions Engineers (Off Site) Legal Practices Office Workers Sales Agents Assembly Workers Catering Industry Workers Domestic Carpenters Domestic Electricians Food & Drink Production Foremen / Supervisors Inspectors Kitchen Staff Nurses (Hospital) Nurses (Private Practice) Retail Industry Workers Site Surveyors Drivers General Labourers Hotel Cleaners / Porters Messengers Police Public Utilities Workers Site Carpenters Site Electricians Site Plumbers Vehicle Body Workers Vehicle Mechanics Welders	Nationality	Select BRITISH Indian OMANI INDIAN KUWAITI QATARI JORDANIAN SYRIAN SRILANKAN BANGLADESHI SINGAPOREAN JAPANESE MALAYSIAN EGYPTIAN SUDANESE KENYAN ZANZIBAREAN AMERICAN CANADIAN SOUTH AFRICAN FRENCH GERMAN ITALIAN AUSTRALIAN NEW ZEALANDER CHINESE KOREAN LEBANESE PAKISTANI BAHRAINI SAUDI ARABIAN EMIRATES NATIONAL TUNISIAN IRANIAN IRAQI THAI PALESTINIAN TANZANIAN DUTCH SWEDISH AFGHANISTANI ALGERIAN ANGOLAN ARGENTINIAN BAHAMIAN BELGIAN BERMUDAN BOLIVIAN BRAZILIAN BULGARIAN BURUNDIAN CAMBODIAN GREEK IRISH MAURITANIAN MEXICAN MOZAMBICAN NEPALESE NIGERIAN NORWEGIAN POLISH PORTUGUESE RUSSIAN SENEGALESE SOMALIAN CEYLONESE SWISS TAIWANESE YEMENI MALTESE FILIPINO ALGERIAN AUSTRIAN DANISH MOROCCANS(MUGRIBI) ** NATIONALITY ** CYPRIOT INDONESIA FHILIPHINES PANAMANIAN VENEZUEALA TURKISH SERBIAN
Company/Sponsor Name
Address Line1
Address Line2
Country	Select Sultanate of Oman
Phone		Fax
GSM		EMail
Cover Details
Date of Arrival in Oman
From Date: (dd/MM/YYYY)		To Date: (dd/MM/YYYY) *
*  Date of exit from oman , whichever is earlier
Sum Assured	Select RO 5000.000
Beneficiary Details for Death Benefit
Beneficiary Name:		Beneficiary Relationship	Select Spouse Son Daughter Self Father Mother Brother sister
Address Line1
Address Line2
Country	Select Sultanate of Oman
Phone
Declaration
I agree that this proposal shall form the basis of the membership under the insurance scheme. I hereby declare that i am residing in Oman.I authorise the insurer to seek medical information from any source in future in case of a claim.I have read the terms and conditions of the scheme and i here by agree to the conditions.			YesNo