*All fields marked in red are mandatory
Personal Details
"Eligible only for residents of Sultanate of Oman"
Name(as in passport)			Gender	MaleFemale
Date of Birth			Age
Address
PO Box			Postal Code
Area			Country	Sultanate of Oman
Phone No.			Fax Number
GSM			EMail Address
Passport Number			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
Nominee Details
Nominee Name			Relationship of nominee (with proposer)	Select Spouse Son Daughter Brother sister Self Father Mother
Gender	MaleFemale		Date of Birth
PO Box			Postal Code
Area			Country	Sultanate of Oman
Phone No.			Fax Number
GSM			EMail Address
Travel Details
Area of Travel	Select Europe and Indian Sub Continent Within Gulf States (GCC) Worldwide excluding USA and Canada Worldwide Including USA and Canada
Date of Commencement of Journey from Oman			Date of Return to Oman
Period of Insurance			Winter Sports Extension	YesNo
Declaration
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				Yes No