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    The New India Assurance Company Limited: Application Form For Euromed Series

    Uploaded by

    Muhammad Siddiuqi
    This document is an application form for a EuroMed health insurance plan from The New India Assurance Company. It requests information such as the applicant's name, nationality, gender, marital status, date of birth, visa details, plan selection, sum insured, and contact information. The form notes that all family members must be covered under the same plan and requests a signature. It provides contact information for the insurance agents handling applications from Dubai and northern emirates.

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    © All Rights Reserved
    Download as PDF, TXT or read online from Scribd

    The New India Assurance Company Limited: Application Form For Euromed Series

    Uploaded by

    Muhammad Siddiuqi
    67 views1 page
    This document is an application form for a EuroMed health insurance plan from The New India Assurance Company. It requests information such as the applicant's name, nationality, gender, marital status, date of birth, visa details, plan selection, sum insured, and contact information. The form notes that all family members must be covered under the same plan and requests a signature. It provides contact information for the insurance agents handling applications from Dubai and northern emirates.

    Original Description:

    New India Insurance Form

    Original Title

    Proposal Form Dha

    Copyright

    © © All Rights Reserved

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    This document is an application form for a EuroMed health insurance plan from The New India Assurance Company. It requests information such as the applicant's name, nationality, gender, marital status, date of birth, visa details, plan selection, sum insured, and contact information. The form notes that all family members must be covered under the same plan and requests a signature. It provides contact information for the insurance agents handling applications from Dubai and northern emirates.

    Copyright:

    © All Rights Reserved
    Download as PDF, TXT or read online from Scribd
    Download as pdf or txt
    67 views1 page

    The New India Assurance Company Limited: Application Form For Euromed Series

    Uploaded by

    Muhammad Siddiuqi
    This document is an application form for a EuroMed health insurance plan from The New India Assurance Company. It requests information such as the applicant's name, nationality, gender, marital status, date of birth, visa details, plan selection, sum insured, and contact information. The form notes that all family members must be covered under the same plan and requests a signature. It provides contact information for the insurance agents handling applications from Dubai and northern emirates.

    Copyright:

    © All Rights Reserved
    Download as PDF, TXT or read online from Scribd
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    THE NEW INDIA ASSURANCE COMPANY LIMITED

    APPLICATION FORM FOR EUROMED SERIES


    DATE:
    PLEASE SELECT YOUR TPA:

    MEMBER NAME

    Sr. No.

    NATIONALITY

    GENDER
    (M/F)

    MARITAL STATUS MARRIED

    YES

    NO

    YES

    NO

    YES

    NO

    YES

    NO

    YES

    NO

    YES

    NO

    YES

    NO

    YES

    NO

    YES

    NO

    10

    YES

    NO

    SUM INSURED : AED 150,000

    RELATION
    (INSURED/
    SPOUSE/ CHILD)

    ABU DHABI / AL AIN

    DUBAI

    OTHER EMIRATES

    SUM INSURED : AED 250,000

    SUM INSURED : AED 500,000

    SUM INSURED : AED 1 MILLION

    VISA ISSUED FROM:

    PLAN SELECTION:

    DOB
    (DD/MM/YYYY)

    PLEASE

    RIAYAH

    GOLD

    DIAMOND

    PLATINUM

    RIAYAH PLUS

    GOLD PLUS

    DIAMOND PLUS

    PLATINUM PLUS

    If opting for EUROMED PLATINUM, please select from the below options:
    Including USA & Canada
    Excluding USA & Canada
    CONTACT DETAILS:

    ADDRESS
    LANDLINE / MOBILE
    FAX
    EMAIL

    Would you like The New India Assurance Company Limited to send health related SMS and Mail?

    YES

    NO

    Note: Please enclose Medical History Form, Passport copy with Visa page & color photograph.
    All members of the family to be covered under the same plan only.
    *All requested details are mandatory.
    The validity for this proposal is for 1 month from the date this application form is filled up.

    SIGNATURE
    Rais Hassan Saadi Insurance Agents L.L.C.: Chief Agents For Dubai Northern Emirates
    P.O. Box : 5701, Dubai, UAE Tel: + 971 4 3525563/3522539, Fax : +971 4 3518544
    E-mail : newindia@nia-dubai.com Website : www.nia-dubai.com

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