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Insurance Coverage of the Sri Lankans Employed in the Middle Eastern Region

Recruitment Agent Name

Covered Member Name

Date of Birth

Passport Number

Visa File Number.

Visa Country

Insured Contact Number

Insured Home Contact Number

Insured Email

Insured Address in Visa Country

Insured Address in Home Country

Beneficiary Address

Beneficiary Name

Beneficiary Email Address

Beneficiary Relationship

Beneficiary Date of Birth

Guardian Name

Guardian Email Address

Guardian Relation With Beneficiary

Guardian Date of Birth

Policy effective Date

Policy Period

I am a non-resident of the UAE.
I will be outside the UAE and will not be visiting the UAE during the effective period of the insurance policy.

I understand and agree to the terms of acceptence

Permitted file types: JPG, PNG, JPEG, GIF, PDF, DOC, DOCX

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